NPR Document 31

Running head: NURSING PROCESS PAPER

Nursing Process Recording

Kimberly E. Fuller

Kent State University

11 October 2005

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Kent State University N30040Medical Information

Student Name: Kimberly Fuller Date of clinical: September 20, 2005

Pt. Initials Room Number Age Gender Admission

MP 252 77 Female 2/15/2005

Primary Medical Diagnosis: Stroke (CVA)

Definition, S/Sx, Treatment, Citation(s): A CVA is the interruption of blood flow in one or more of the blood vessels that supply the brain. Stroke is the leading cause long-term disability and the third highes cause of death in the United States (Elmore & Miller, 2005). Tissues become ischemic, leading to hypoxia or anoxia with destruction or necrosis of the neurons, glia, and vasculature (Sommers & Johnson, 2002). There are two types of strokes, embolism (ischemic) and hemorrhagic. Early signs of an impending ischemic stroke are transient hemiparesis, hemiosensory loss, and loss of speech. A hemorrhagic stroke occurs very rapidly, with symptoms developing in minutes to hours. Symptoms of hemorrhagic strokes include occipital or nuchal headaches, vertigo or syncope, epistaxis, retinal hemorrhages, parethesias, and transient paralysis. Also, symptoms must persist longer than 24 hours to be diagnostic of a stroke (Minton, 2005). “If certain conditions are met, IV-t-PA can be administered within three hours of a stroke to reduce chances of death and disability” (Elmore & Miller, 2005, p.58). Medical management of a CVA includes support of vital functions and ongoing surveillance to identify early neurologic changes as the patient’s condition evolves. Treatment consists of maintaining life, reducing ICP, preventing complications, and limiting the extension of the CVA. For patients that cannot maintain their own airway and circulation independently, ventilation, intubation, and oxygen may be required. If the CVA is hemorrhagic, surgery may be needed to stop the bleeding or remove the hematoma. Also, physical therapy is very important and should begin as soon as the patient’s condition stabilizes. One should use passive range of motion exercise to prevent the development of contractures on the affected side. Lastly, strengthening the unaffected side is important because it helps to compensate for the losses on the affected side (2002).

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Secondary Medical Diagnosis: Schizophrenia

Definition, S/Sx, Treatment, Citation(s): “Schizophrenia is a mental disorder characterized by disturbed thought processes, altered perception, and labile affect” (Margolis, 2001, p.375). There are five types of schizophrenia. Paranoid schizophrenia is characterized by the presence of delusional thinking and hallucinations. The paranoid schizophrenic is fairly organized in speech and behavior and can possibly show some range in affect. Disorganized schizophrenia is characterized by disorganized speech and behavior and flat, or inappropriate, affect. Disorganized schizophrenics can also have delusions and hallucinations. Residual schizophrenia is characterized by alterations in range of affect and thinking patterns. Undifferentiated schizophrenia is characterized by the presence of two or more of the following symptoms: hallucinations, delusions, flat affect, and disorganized speech or behavior. Lastly, catatonic schizophrenia is characterized by strange motor activity. Catatonic schizophrenics can be mute or show incoherent speech (Shoemaker, 2005). A complete health history, physical, and psychiatric examination are very important in the treatment of schizophrenia. It is important that the individual be kept safe from others and safe from self. Medications include lithium salts and antipsychotics. Medications are started out at low doses and are gradually bought up (2001). Lastly, psychotherapy is very important in the treatment of schizophrenia because of the negative manifestation and severe social impairments (2005).

Surgery & Date of Surgery: Client has no record of surgeries in hard chart or ECS.

Explanation of surgery, citation(s):

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KENT STATE UNIVERSITYCOLLEGE OF NURSINGDRUG INFORMATION

Date: 9/20/2005 Patient’s Intials:MP Patient Diagnosis: Stroke

Drug Indications for Use Side Effects Nursing Responsibilities

Generic: diltiazem

Trade: Cardizem, Cardizem LA, CartiaXT, Dilacor XR, Diltia XT, Nu-Diltiaz, Tiamate, Tiazac

Dose: 30mg tab

Frequency/Route: tid via enteral tube

Pharmacotherapeutic: calcium channel blockers

Clinical: antianginals, antiarrhythmics (class IV), antihypertensives

General Use: Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction. Thereby resulting in systemic vasodialation (decreased BP), coronary vasodialation, and suppression of arrhythmias.

Reason for giving this drug to this client: Management of clients HTN.

Serious side effects include arrhythmias, CHF, and Stevens-Johnson Syndrome. Another side effect, less serious though, is peripheral edema.

BP and pulse should be monitored periodically during therapy. The nurse should assess for signs of CHF such as, peripheral edema, dyspnea, weight gain, jugular venous distention, and rales/crackles. Also, the nurse should monitor ECG continuously during administration and report any signs of bradycardia and prolonged hypotension immediately. This could be a sign of an arrhythmia.

Drug-Drug interactions with NSAID’s.

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Drug Indications for Use Side Effects Nursing Responsibilities

Generic: lactulose

Trade: Cephulac, Cholac, Constulose, Duphalac, Enulose, Evalose, Heptalac, Kritalose, Lactulose PSE, Portalac

Dose: 30mL

Frequency/Route: tiw via enteral tube

Pharmacotherapeutic: osmotics Clinical: laxatives

General Use: Increases the water content and softens the stool and lowers the pH of the colon. Consequently, relief of constipation and decreased blood ammonia levels are achieved.

Reason for giving this drug to this client: Managements of clients constipation.

Side effects include belching, cramps, distention, flatulence, diarrhea, and hyperglycemia in diabetic patients.

Bowel assessment should be performed. The nurse should also assess color, consistency, and amount of stool produced. Lastly, the nurse should monitor glucose levels and serum electrolytes with chronic use.

Generic: acetaminophen

Trade: Tylenol

Dose: 650mg

Frequency/Route: tid via enteral tube

Pharmacotherapeutic:

Clinical: antipyretics, non-opioid analgesics.

General Use: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Consequently, this drug achieves analgesia and antipyresis.

Reason for giving this drug to this client: Management of clients pain.

Severe side effects include hepatic failure and hepatoxicity. Other side effects include renal failure, rash, urticaria.

Assess type, location, and intensity prior to and 30-60minutes following administration. If given for fever note signs of diaphoresis, tachycardia, and malaise. Lastly, hepatic, hematologic, and renal function should be assessed.

Drug-Drug interactions with NSAID’s.

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Drug Indications for Use Side Effects Nursing Responsibilities

Generic: oxycodone

Trade: Endocodone, M-Oxy, Oxycontin, OxyFAST, OxyIR, Percolone, Roxicodone SR

Dose: 5mg

Frequency/Route: q.d. via enteral tube

Pharmacotherapeutic: opioid agonists, opioid agonists/nonopiod analgesic combinations

Clinical: opioid analgesic

General Use: Binds to opiate receptors in the CNS and alters the perception of and response to painful stimuli, while producing generalized CNS depression resulting in decreased pain.

Reason for giving this drug to this client: Management of clients pain.

A serious side effect is respiratory depression. Other side effects include confusion, sedation, and constipation.

The nurse should perform a pain assessment. The nurse should also perform a bowel assessment and monitor BP, pulse, and RR. The nurse may also want to watch plasma amylase and lipase levels.

Drug-drug interactions with sedatives and hypnotics.

Generic: risperidone

Trade: Risperdal, Risperdal M-TAB

Dose: 1.5mg

Frequency/Route: b.i.d. via enteral tube

Pharmacotherapeutic:

Clinical: antipsychotic

General Use: May act by antagonizing dopamaine and serotonin in the CNS. Consequently, this drug results in decreased symptoms of psychosis.

Reason for giving this drug to this client: Management of clients schizophrenia.

A serious side effect is neuroleptic malignant syndrome. Other side effects include aggressive behavior, dizziness, extrapyramidal reactions, headache, increased dreams, increased sleep duration, insomnia, sedation, pharyngitis, rhinitis, visual disturbances, cough, constipation, diarrhea, dry mouth, nausea, decreased libido, dysmenorrheal/menorrhagia, itching/skin rash, and weight gain.

The nurse should monitor the patients mental status and assess for mood changes. Also, the nurse should monitor for onset of extrapyramidal side effects, tardive diskinesia, and development of neoroleptic malignant syndrome. Lastly, the nurse should know that this drug can cause increased serum prolactin, AST, and ALT. Risperidone can also cause anemia, thrombocytopenia, leukocytosis, and leucopenia.

Drug-Drug interactions with NSAID’s and antacids.

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Drug Indications for Use Side Effects Nursing Responsibilities

Generic: quetiapine

Trade: Seroquel

Dose: 150mg

Frequency/Route: q.d. at 8pm/hs via enteral tube

Pharmacotherapeutic:

Clinical: antipsychotic

General Use: Probably acts by serving as an antagonist of dopamine and serotonin thereby decreasing manifestation of psychoses.

Reason for giving this drug to this client: Management of client’s schizophrenia symptoms.

Two serious side effects are neuroleptic malignant syndrome and seizures. Other side effects include dizziness and weight gain.

The nurse should monitor patient’s mental status and monitor for mood changes. Also, the nurse should monitor for onset of extrapyramidal side effects, tardive diskinesia, and development of neoroleptic malignant syndrome. Seroquel can also cause anemia, thrombocytopenia, leukocytosis, and leucopenia.

Drug-Drug interactions with opioid analgesics ad sedatives/hypnotics.

Generic: moxifloaxcin

Trade: Avelox

Dose: 400mg

Frequency/Route: q.d. at 8pm/hs via enteral tube

Pharmacotherapeutic:

Clinical: anti-infective

General Use: Ingibits bacterial DNA synthesis by inhibiting DNA gyrase thereby producing death of susceptible bacteria (Deglin & Vallerand, 2005).

Reason for giving this drug to this client: Management of client’s pneumonia.

Severe side effects include seizures, arrhythmias, pseudomembranous colitis, anaphylaxis, and Stevens-Johnson Syndrome. Other side effects include dizziness, drowsiness, headache, insomnia, abdominal pain, diarrhea, and nausea (Deglin & Vallerand, 2005).

The nurse should assess the patient for signs and symptoms of anaphylaxis and infection. The nurse should also be aware that this drug can cause hyperglycemia, hyperlipidemia, increased WBC count, increased serum calcium, chloride, albumin, and globulin. Decreases in glucose, Hgb, RBC’s, neutophils, eosinophils, and basophils can occur (Deglin & Vallerand, 2005).

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Drug Indications for Use Side Effects Nursing Responsibilities

Generic: metoclopramide

Trade: Clopra, Octamide, Octamide-PFS, Reclomide, Reglan

Dose: 10mg (10ml)

Frequency/Route: q.i.d. via enteral tube

Pharmacotherapeutic:

Clinical: antiemetics

General Use: Blocks dopamine receptors in chemoreceptor trigger zone of CNS and stimulates motility of upper GI tract and accelerates gastric emptying. Consequently, this drug produces decreased N/V and symptoms of gastric stasis (Deglin & Vallerand, 2005).

Reason for giving this drug to this client: Management of client’s N/V.

Symptoms include drowsiness, extrapyramidal reactions, and restlessness (Deglin & Vallerand, 2005).

The nurse should assess the patient for N/V, abdominal distention, bowel sounds before and after, extrapyramidal side effects, tardive dyskinesia, and for signs of depression. Also, the nurse should know that this drug could alter hepatic function test results.

Drug-Drug interactions with CNS depressants, opioid analgesics, and sedative/hypnotics (Deglin & Vallerand, 2005).

Generic: ipatropium

Trade: Atrovent

Dose: 1UD-0.02% inh. sol.

Frequency/Route: q.i.d via aerosol PRN

Pharmacotherapeutic: enzyme inhibitors

Clinical: antineoplastics

General Use: Inhibits cholinergic receptors bronchial smooth muscle, resulting in decreased concentrations of cGMP. Consequently, this drug produces bronchodialation without any systemic anticholinergic effects (Deglin & Vallerand, 2005).

Reason for giving this drug to this client: Management of client’s SOB when it occurs

Side effects include dizziness, headache, nervousness, blurred vision, sore throat, bronchospasm, cough, hypotension, palpitations, GI irritation, and nausea (Deglin & Vallerand, 2005).

The nurse should assess for allergies to atropine and belladonna alkaloids.

Assess respiratory status before and after administration (Deglin & Vallerand, 2005).

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Drug Indications for Use Side Effects Nursing Responsibilities

Generic: albuterol

Trade: AccuNeb, Airet, Proventil, Proventil HFA, salbutamol, Ventodisk, Ventolin, Ventolin HFA, Volmax, VoSpira ER

Dose: 1UD-0.083% inh. sol.

Frequency/Route: q.i.d. via aerosol PRN

Pharmacotherapeutic: adrenergic

Clinical: bronchodialators

General Use: Binds to beta2-adrenergic receptors in the smooth muscle of the airway, leading to activation of adenyl cyclase and increased levels of cAMP. Therefore subsequent relaxation of airway smooth muscle with subsequent bronchodialation is achieved (Deglin & Vallerand, 2005).Reason for giving this drug to this client: Management of client’s SOB when it occurs.

Side effects include nervousness, restlessness, tremor, chest pain, and palpitations (Deglin & Vallerand, 2005).

Assess lung sounds, pulse, and BP before and after administration. The nurse should also periodically monitor pulmonary function tests and observe for wheezing. Lastly, the nurse should be aware that this drug could cause a decrease in serum potassium (Deglin & Vallerand, 2005).

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Drug Indications for Use Side Effects Nursing Responsibilities

Generic: sennosides

Trade: Black-Draught, Ex-Lax, Ex-Lax Chocolated, Fletchers’ Castoria, Maximum Relief Ex-Lax, Sena-Gen, Senexon, Senokot, SenokotXTRA.

Dose: 2tsps (10ml)

Frequency/Route: q.d. via enteral tube

Pharmacotherapeutic: stimulant laxatives

Clinical: laxatives

General Use: Active components of sennosides alter water and electrolyte transport in the large intestine, resulting in accumulation of water and increased peristalsis, thereby producing a laxative action (Deglin & Vallerand, 2005).Reason for giving this drug to this client: Management of client’s chronic constipation.

Common symptoms include cramping and diarrhea (Deglin & Vallerand, 2005).

Nurse should perform a bowel assessment and assess the color, consistency, and amount of stool (Deglin & Vallerand, 2005).

Generic: acetaminophen

Trade: Tylenol

Dose: 650mg

Frequency/Route: q6h via enteral tube PRN

Pharmacotherapeutic:

Clinical: antipyretics, non-opioid analgesics.

General Use: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Consequently, this drug achieves analgesia and antipyresis (Deglin & Vallerand, 2005).

Reason for giving this drug to this client: Management of clients pain.

Severe side effects include hepatic failure and hepatoxicity. Other side effects include renal failure, rash, urticaria (Deglin & Vallerand, 2005).

Assess type, location, and intensity prior to and 30-60minutes following administration. If given for fever note signs of diaphoresis, tachycardia, and malaise. Lastly, hepatic, hematologic, and renal function should be assessed (Deglin & Vallerand, 2005).

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Drug Indications for Use Side Effects Nursing Responsibilities

Generic: oxycodone

Trade: Endocodone, M-Oxy, Oxycontin, OxyFAST, OxyIR, Percolone, Roxicodone SR

Dose: 5mg

Frequency/Route: q3h via enteral tube PRN

Pharmacotherapeutic: opioid agonists, opioid agonists/nonopiod analgesic combinations

Clinical: opioid analgesic

General Use: Binds to opiate receptors in the CNS and alters the perception of and response to painful stimuli, while producing generalized CNS depression resulting in decreased pain (Deglin & Vallerand, 2005).

Reason for giving this drug to this client: Management of client’s breakthrough pain.

A serious side effect is respiratory depression. Other side effects include confusion, sedation, and constipation (Deglin & Vallerand, 2005).

The nurse should perform a pain assessment. The nurse should also perform a bowel assessment and monitor BP, pulse, and RR. The nurse may also want to watch plasma amylase and lipase levels (Deglin & Vallerand, 2005).

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Diagnostic Tests: Results of significant diagnostic tests should be recorded under appropriate functional health pattern.

Laboratory Analysis:

Test Date Test Name

Normal Range

Client Results Interpretation of Abnormal Results For Your Client

9/16/2005 Sodium 136-145 142 WNL

9/16/2005 Chloride 98-107 104 WNL

9/16/2005 Glucose 70-105 153 This test is a measure of the amount of glucose in the blood. A high amount of glucose in the blood would be indicative of Diabetes Mellitus. This result would be consistent with my client’s diagnosis of TypeII Diabetes Mellitus (Fischbach, 2004).

9/16/2005 Creatinine 0.6-1.3 0.6 WNL

9/16/2005 Electrolyte Balance

4-18 12 WNL

9/16/2005 Potassium 3.5-5.1 4.2 WNL

9/16/2005 CO2 22-29 30 An elevated CO2 is characteristic of respiratory alkalosis. This result would be consistent with the poor inspiration of my client (Fischbach, 2004).

9/16/2005 BUN 7-18 18 WNL

9/16/2005 Calcium 8.4-10.2 8.7 WNL

8/18/2005 WBC 4.8-10.8 5.2 WNL

8/18/2005 HgB 12-16 12.9 WNL

8/18/2005 MCV 80-100 95.9 WNL

8/18/2005 MCHC 31-37 33.5 WNL

8/18/2005 RDW 11.5-14.5%

13.5% WNL

8/18/2005 RBC 4.0-5.5 4.01 WNL

8/18/2005 Hct 36-46 38.4 WNL

8/18/2005 MCH 26-34 32.1 WNL

8/18/2005 Platelets 130-400 187 WNL

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STUDENT NAME: Kimberly FullerDATABASE

Subjective Data Objective Data

HEALTH PERCEPTION - HEALTH MANAGEMENT (General Survey, TPR)

Client severely aphasic. Elderly female lying in a semi-fowlers position. She was awake and appeared to be watching TV. She appeared to be very tired. Client was unable to speak or answer any questions due to severe aphasia. However, client was cooperative at al time when I was in the room. Noted a wheelchair inside the room. Vitals were 97.9, 93, 18, and 122/72.

NUTRITIONAL/METABOLIC(Skin, Hair, Nails; Head and Neck; Mouth, Nose, Sinus)

Client severely aphasic. Client has a PEG tube in place and relies on it for all nutrition. Pump was running at a rate of 50cc/hr while in the room. Client appeared to be tolerating her feed well. Skin: The patient’s skin was pale, warm, and well hydrated. Skin was absent of any breakdowns or wounds. Both radial and pedal pulses were palpable. They were both at a measure of +2. Hair: The client had a full head of hair that was grey and white. Hair was non-oily or coarse and was well kept. Nails: Fingernails were clear with a brisk capillary refill. Toenails: The toenails were thick and brittle. Eyes: Extraocular movements were intact. PERLA. Head and Neck: Trachea midline and no evidence of bruit. Patient unable to move head/neck. Ears: No cerumen noted. Mouth: mucosa was pink and moist. Although the client’s lips were slightly cyanotic. No other part of her body exhibited signs of cyanosis. Also noticed that client had no teeth and did not have any dentures.

ELIMINATION(Bowel, bladder & abdomen)

Client severely aphasic. Bowel sounds present in all four quadrants. Abdomen was soft and non-distended and the umbilicus was centered. Client had one large watery BM while on shift. Client did not void while on shift.

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ACTIVITY/EXERCISE(Heart, lungs, MSK)

Client severely aphasic. Heart: no rhythm abnormalities noted and had an apical pulse of 93. No visible palpations were noticed. Musculoskeletal: Client unable to bare weight. Negative for movement in all four extremities. Client starting to develop contractures in both hands. Needed total assistance for all care. RR was 18.

Lung sounds diminished upper/lower bilaterally with some crackles present in the upper lobes.

SEXUALITY/REPRODUCTION(Breast, testes, abdomen (partial)Genitourinary-Reproductive)

Client severely aphasic. Post-menopausal. Breasts equal on both sides and areola dark in color.

SLEEP/REST(Appearance, Behavior)

Client severely aphasic. Client slept on an off throughout my entire shift. She was very restless. She would fall asleep for a few minutes and would wake right back up.

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COGNITIVE/PERCEPTUAL(alertness, memory, neurologic, sensory)

Client severely aphasic. Unable to assess memory due to severe aphasia. Client appeared to be oriented to person because she would follow me with her eyes when I spoke to her and moved around the room. Client was cooperative while I cared for her. However, client did cry once when asked about a teddy bear that was in her room.

ROLE/RELATIONSHIP(Family response communication; response, visitation)

Client severely aphasic.Client had a lot of family photos and cards in her room. Husband also visits 2x/day everyday. Husband was very interested in her care and helped as much as he possible could.

SELF-PERCEPTION/SELF-CONCEPT (Appearance, behavior, mood)

Client severely aphasic. Client either appeared sad or had an expressionless look on her face while she was in bed.

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COPING/STRESS(mental status, mannerisms)

Client severely aphasic. Client cried out several times while on shift. When this would happen I would just go in her room and sit with her until she calmed down.

VALUES/BELIEFS(Religious practice; behaviors; expressions)

Client severely aphasic. Client had many religious artifacts in her room. There were religious pictures, cards, candles, etc.

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NURSING DIAGNOSES LIST

Develop a list of both actual and potential (risk) nursing diagnoses identified for you client. Place a star before your primary nursing diagnoses for which you will develop a care plan.

For each diagnosis, list at least 4-5 pieces of supporting data*

*1. Risk for impaired skin integrity related to immobility: AEB-Altered sensation—diagnosis of stroke-Alteration in nutritional state—PEG tube-Moisture—incontinence-Extremes of age—advanced age (77)-Inability to ambulate, move, or reposition

2. Risk for sleep deprivation related to disturbed sleep pattern: AEB-Hallucinations—diagnosis of Schizophrenia-Husband stating, “She can’t sleep with all these people moving in and out and changing

the T.V. on her.”-Acute confusion—dementia-Sustained unfamiliar or uncomfortable sleep environment—being in a long term care

facility.3. Risk for social isolation related to residing in a long term care facility: AEB

-Sad, dull affect-Lack of participation in group activities-Uncommunicative behavior-Mental handicap—schizophrenia and dementia

4. Powerlessness related to self care inability: AEB-Dependence on others for ADL’s-Healthcare environment-Passivity-Inability to seek information regarding care

5. Impaired religiosity: AEB-Barriers to practicing religion-Lack of social interaction-Aging-End-stage life crises—DNR-CC status

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Subjective Data Objective Data Indirect DataClient severely aphasic and unable to provide any subjective data.

Client has development of contractures in both hands and feet. Client completely immobile.Client incontinent of urine and stool.Client severely aphasic.

Diagnosis of stroke.Diagnosis of dysphagia.

Data Group (include at least 5). Indicate source of data.

Interpretation with documentation

1. Stroke (Diagnoses Tab in ECS, 10/14/2004). “Stroke is a term used to describe neurologic changes caused by an interruption in the blood supply to part of the brain” (Bowman, 2005, p.2107).

2. Dysphagia (Physicians Progress Notes, 9/1/2005). Dysphagia is difficulty swallowing (Potter & Perry, 2005). Dysphagia is a common clinical manifestation of a stroke. Cranial nerves V, VII, and XII are involved in swallowing. Strokes in the area of the vertebrobasilar system cause stroke (Bowman, 2005).

3. Client incontinent of urine and stool (Objective data). “Urinary incontinence is the involuntary loss of urine that is sufficient to be a problem” (Potter & Perry, 2005). Stroke can cause bowel and bladder incontinence. Nerves send messages to the brain, but the brain does not correctly interpret the message. The extent of incontinence is determined y the extent and location of the infarct (Bowman, 2005). Continued incontinence and create the potential for skin breakdown (2005).

4. Client severely aphasic (Objective Data). The deficit in communication ability is aphasia. Aphasia involves speaking, reading, writing, and understanding spoken language. Broca’s aphasia affects speech production. This result in problems with speech expression (Bowman, 2005). If language after stroke is fragmentary or you have to guess a client’s meaning, the client is most likely aphasic (Elmore & Miller, 2005).

5. Client has development of contractures in hands and feet

(Objective Data).

The development of contractures is an effect of immobility. Exercise is important in the prevention of contractures. Individuals who have had a stroke may need rehabilitation to help them regain mobility again (Hogstel, 2001).

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NANDA NOC NICNursing Diagnosis: 1: Risk for impaired skin integrity r/t immobility.

AEB: Altered sensation, alteration in nutritional status, incontinence, extremes of age, and inability to move.

Definition (source): At risk for skin being adversely, altered. (NANDA, 2005)

NOC (Nursing Outcome Classification: Tissue Integrity: Skin and Mucous Membranes

Definition (source): Structural intactness and normal physiological function of skin and mucous membranes. (Moorhead, p.544)

Indicators: Client at a level 5, none, for skin lesions, mucous membrane lesions, skin flaking, skin scaling, erythema, and blanching. (Moorehead, p.544)

STG: Reduce precipitating factors of skin breakdown over the next 2-3 weeks.

LTG: Client will remain at a level 5 for skin integrity throughout her stay Jennings

Intervention: A. Pressure management. (Dochterman, 581)

Definition (source): Minimizing pressure to body parts. (Dochterman, 581)

Intervention: B. Skin surveillance. (Dochterman, p.657)

Definition (source): Collection and analysis of patient data to maintain skin an mucous membrane integrity. (Dochterman, p.657)

Activity 1A: Monitor the client’s nutritional status. (Dochterman, p.581)

Nursing Order: Assess client for signs and symptoms of dehydration q shift.

Rationale: Dehydration and edema can increase the rate of skin breakdown in the immobilized client (Potter & Perry, 1441).

Evaluation: Examined clients skin turgor, eyes, and urine and

Activity 2A: Monitor for sources of pressure and friction. (Dochterman, p.581)

Nursing Order: Perform skin assessment q shift during AM care while bathing.

Rationale: Nurses must routinely assess the skin to look for primary or initial wounds that may develop (Potter & Perry, 687).

Evaluation: During AM care found the skin to be intact and no evidence of breakdown was noted.

Activity 3A: Turn/position client on a regular schedule. (Dochterman, p.581)

Nursing Order: Reposition client in bed or move to wheelchair every 2-3hours.

Rationale: To prevent skin breakdown, immobilized clients should be turned every 2 hours (Potter & Perry, p.1431).

Evaluation: Repositioned client every 2 hours. Client remained comfortable.

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found client to be well hydrated.

Activity 1B: Institute measures to prevent deterioration (Dochterman, p.657).

Nursing Order: Apply seat cushion q shift while client is in wheelchair.

Rationale: Chair cushions must be used to reduce pressure on the ischia while sitting (Black, 412).

Evaluation: Cushion was placed on chair and client remained comfortable.

Activity 2B: Monitor skin for areas of redness and breakdown (Dochterman, p.657).

Nursing Order: Change clients brief as necessary and assess the perineal/rectal areas for evidence of breakdown.

Rationale: The client with fecal incontinence is at risk for skin breakdown when fecal contents remain on the skin (Potter & Perry, 1416).

Evaluation: Change clients brief as needed. Client had one large watery stool.

Activity 3B: Inspect clothing for tightness (Dochterman, p.67).

Nursing Order: Inspect client’s clothing q shift and note any tightness and possible breakdown in that area.

Rationale: With the thinning of the epidermis the skin is easily injured (Hogstel & Talbot, 67).

Evaluation: Inspected patients clothing in the AM and noted that it was twisted around her arms and neck due to her position. I fixed her clothing and noted no signs of breakdown.

NOC Evaluation: Client exhibited no evidence of skin breakdown and remained on a scale of 5. STG goal was met, but need more time for LTG.

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References

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Elmore, S. & Miller, J. (2005). Call a stroke code: Learn how to protect your patient from lasting

disability and possible save his life after an acute ischemic stroke. Nursing, 35 (3), 58-63.

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Fischbach, F. (2004). A Manual of laboratory and diagnostic tests (7th ed.). Philadelphia, PA:

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Hogstel, M. (2001). Nursing facilities. In Hogstel, M. Gerontology: Nursing care of the older

adult. (pp.377-408). Albany, NY: Delmar.

Margolis, S.E. (2001). Mental health issues. In Hogstel, M. Gerontology: Nursing care of the

older adult. (pp.367-384). Albany, NY: Delmar.

Minton, M. (2005). Management of clients with cerebral disorders. In Black, J.M. & Hawks,

J.H. Medical surgical nursing: Clinical management for positive outcomes (7th ed.).

(pp.2073-2106). St. Louis, MO: Elsevier Inc.

Moorhead, S., Johnson, M., & Maas, M. (2004). Nursing outcomes classifications (NOC). 3rd ed.

St. Louis, MO: Mosby.

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NANDA. (2005). Nursing diagnoses: Definitions and classifications. Philadelphia, PA:

NANDA International.

Perry, A. & Potter, P. (2005). Fundamentals of nursing (6th ed.). St. Louis, MO: Elsevier Inc.

Shoemaker, N. Management of clients with cerebral disorders. In Black, J.M. & Hawks,

J.H. Medical surgical nursing: Clinical management for positive outcomes (7th ed.).

(pp.523-536). St. Louis, MO: Elsevier Inc.

Sommers, M.S. (2002). Diseases and disorders: A nursing therapeutics manual (2nd ed.).

Philadelphia, PA: F.A.Davis Company.