Assessment Nursing Diagnosis

RATIONALE Planning Interventions Rationale Evaluation

Objective: Dx: CVD infarct ® prob.

c standby O2

@ bedside

c good capillary refill in 2-3 secs.

c body malaise

2 weeks bedridden

on CBR w/o BRP

c limited ROM

dry skin

Risk for Impaired

Skin Integrity r/t prolonged bed rest and

altered circulation .

Immobility, which leads to pressure, shear, and

friction, is the factor most likely to put an individual

at risk for altered skin integrity. Advanced age;

the normal loss of elasticity; inadequate

nutrition; environmental moisture, especially from

incontinence; and vascular insufficiency

potentiate the effects of pressure and hasten the

development of skin breakdown. Groups of

persons with the highest risk for altered skin

integrity are the spinal cord injured, those who are confined to bed or

wheelchair for prolonged periods of time, those with edema, and those

who have altered sensation that triggers the normal protective

weight shifting. Pressure relief and pressure

reduction devices for the prevention of skin

breakdown include a wide range of surfaces,

specialty beds and mattresses, and other

devices.

After 1-2 hours of nursing

intervention the client and the

relatives will be able to verbalize

understanding of individual factors that contribute to possibility of skin

integrity impairment and

take steps to correct the situation.

As evidence by:

understanding the situation.

patient’s skin remain intact

no redness over bony prominences

Place the pt in a comfortable position Take and record vital signs

Determine age.

Assess general condition of skin.

to prevent backaches or muscle aches.

to note any significant changes that may be brought about by the disease

Elderly patients’ skin is normally less elastic and has less moisture, making for higher risk of skin impairment.

Healthy skin varies from individual to individual, but should have good turgor, feel warm and dry to the touch, be free of

No. evaluation.

(Medical-Surgical Nursing vol. 10th ed. Brunner & Suddarths, pg 1567)

Specifically assess skin over bony prominences

Assess patient’s ability to move.

Reassess skin often and whenever the patient’s condition or treatment plan

impairment, and have quick capillary refill (<6 seconds).

Areas where skin is stretched tautly over bony prominences are at higher risk for breakdown because the possibility of ischemia to skin is high as a result of compression of skin capillaries between a hard surface and the bone.

Immobility is the greatest risk factor in skin breakdown.

The incidence and onset of skin breakdown is directly related to the number of risk factors present.

results in an increased number of risk factors. encourage change of position in a regular basis

provide adequate clothing/covers; protect from drafts emphasize importance of adequate nutritional/ fluid intake recommend keeping nails short

to prevent pressure to certain parts of the body

to prevent vasoconstriction

to maintain general good health and skin turgor

to reduce risk of dermal injury when severe itching is present

(Nursing Care Plan, 6th ed. Gulanick/Myer’s pg.457,525,776

AEJEL ASAÑA GROUP- B20

Assessment Nursing Dx RATIONALE Goals Intervention Rationale EvaluationSubjective:

Impaired physicalCVD can be caused by After 4 hrs of nursing After 4 hrs of nursing

Objective: Limited range

of motion(client can’tfully extendhis right armand hold uphis rightshoulder) Limited

abilityand difficultyto performgross motorskills likeextending andlifting of theright arms

SlowedMovement left arm Dx: CVD

infarct ® prob.

intubated since 4/23/10

FIO2- @ 2-3LPM TV-320, RR-20, PF-60

mobility r/tneuromusculardamage involvement

an occlusion in theblood flow. This canlead to ↓O2 and thecause failure tonourish the tissues atthe capillary level andthat can causeneuromusculardamage w/c can causeimpaired physicalmobility

Medical- Surgical Nursing, vol.2,9th edition, Brunner & Suddarths, page 768 )

intervention, the relatives will beable to participate intherapeutic regimenas evidence by:

Verbalizationunderstanding ofthe situation and therapy

Able to participate

in the interventionsrendered by thenurse

Independent: Determine degree ofImmobility

Observe movementwhen client isunaware

Support affected partwith pillows

Give rest periods toActivities

Encourage adequate

fluids and right dietas necessary to theclient

Independent: Toestablishcomparativebaseline To noteanyincongruencewith thereportsofabilities Reducerisk ofpressureulcers To helpreducefatigueand O2demand ↑ energyproduction

(Nursing Care Plan, 6th edition, Gulanick/Myers pg. 879)

intervention, the relative are able to participate intherapeutic regimen as evidence by:

Verbalizationunderstanding ofthe situation and therapy

Able to participate

in the interventionsrendered by thenurse

Assessment Nursing Dx RATIONALE Goals Intervention Rationale Evaluation

SUBJECTIVE:

Difficultyproducingspeech. Facial

paralysis. Muscle and

facial tension restless noted Un able to communicate CVD patient

Impaired verbalcommunicationrelated to loss oforal muscletone control.

A CVD, which may be

caused by,

hemorrhage,

thrombus, embolism

or vasospasm, can

result in a local area

of cell death, called

infarct. It is caused by

a lack of blood supply

which is then

surrounded by an

area of cells that are

secondarily affected.

Since symptoms

depend on the

location of the stroke

and size of the infarct,

it could involve the

brain’s Brocca’s area,

which is primary

responsible for

communication

through facial

expressions and

speech. By causing

damage to this area,

the patient’s

After 2 hours of nursing interventions, the client will establish method of communication in which needs can be expressed.

As evidence by:

Established eye

contact while

communicating

with others

Used paper and

pen to express

needs

>Monitored vital

signs with emphasis

to BP.

>Provided an

atmosphere of

acceptance and

privacy through

speaking slowly and

in a normal tone, not

forcing the client to

communicate.

>Taught techniques

to improve speech

by initially asking

>Establishes baseline

data for review of

existing conditions.

>Impaired ability to

communicate

spontaneously is

frustrating and

embarrassing. Nursing

actions should focus

on decreasing the

tension and conveying

an understanding of

how difficult the

situation must be for

the client

>Deliberate actions

can be taken to

improve speech. As

After 2 hours of nursing

intervention the goal was

met the client established

method of

communication in which

needs are expressed

As evidenced by :

Established eye

contact while

communicating

with others

Used paper and

pen to express

needs

communicating skills

are greatly altered

and affected.

(Medical- Surgical Nursing, vol.2,9th edition, Brunner & Suddarths, page 1259 )

questions that client

can answer with a

“yes” or “no”.

>Used strategies to

improve the client’s

comprehension by

using touch and

behavior to

communicate

calmness and adding

other non – verbal

methods of

communication such

as pointing or using

flash cards for basic

needs; using

pantomime; or using

paper and pen.

>Involved the

significant others in

the plan of care.

>Educated relatives

the client’s speech

improves, his

confidence will

increase and she will

make more attempts

at speaking.

>Improving the

client’s

comprehension can

help to decrease

frustration and

increase trust. Clients

with aphasia can

correctly interpret

tone of voice.

>Enhances

participation and

commitment to plan.

>Imparts thought and

to establish a

method of

communication

through sign

language.

answers the needs of

the client with

lessened difficulty.

(Nursing Care Plan, 6th

edition,

Gulanick/Myers pg.

565)