NCP Impaired Skintissue Integrity

7/28/2019 NCP Impaired Skintissue Integrity

1/5

Art Christian M. Ramos Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess

BSN 4 - 3 July 10, 2013

Patient: X

Assessment Diagnosis Inference Planning Interventions Rationale Evaluation

Subjective: N/A

due to patient canonly mouth words

when asked or

when she needs

something.

Objective:

ReceivedSleeping but

arousable

c Nasogastrictube intact

and patent for

feeding(NPO

temporarily)

c endotrachealtube @ 22mm

leveled

connected to

Mechanical

Ventilatior c

settings @ :

Fi02 = 40%

TV = 400ml

IFR = 55

BUR = 16

18 AC mode

c IVF 1LPNSS leveled

@ 720cc,

infusing @

80cc/hr.

c foleycatheter

Impaired Tissue

Integrity relatedto prolonged

immobilization

secondary to

spinal cord

injury.

Skin is the primary

defense of the body; itprotects the body

against infections and

diseases brought about

by the invasion of

microbes in the body.

A normal skin is moist

and intact; dryness of

the skin is more prone

to friction that may

result to impairment of

the skin integrity as

compared with a moist

skin. Tissue

In anatomy, the

term soft tissue refers

to tissues that connect,

support, or surround

other structures

and organs of the body,

not being bone. Soft

tissueincludes tendons, ligam

ents, fascia, skin, fibrou

s tissues, fat,

and synovial

membranes (which

are connective tissue),

and muscles, nerves an

d blood vessels (which

After 8 hours of

effective nursingintervention,

patient will be

able to:

Manifestsigns of

comfort

from wound

Manifestsigns of

healing and

reduction of

pressure

ulcers

Vital signswithin

normal

limits.

Assess betweenfolds of skin,remove anti

embolic

stockings or

devices & use a

mirror to see the

heels. Also

assess under

oxygen tubing

especially on

the ears & the

cheek, beneath

splints and

under medical

devices.

Note objectivedata of pressure

ulcer (stage,

length, width,

depth, wound

bed appearance,drainage &

condition of

periulcer tissue)

Pressure ulcersunder medicaldevices are

commonly

overlooked.

Reassessmentof ulcer is

completed

each time

dressing are

changed or

sooner if ulcer

shows

manifestations

of

deterioration.

Analyses of

the trends in

healing are

important step

After 8 hours of

effective nursingintervention,

patient

manifested:

Signs ofcomfort bybeing able to

rest and sleep

for long

periods

Manifestsigns ofhealing by

applying

silver

sulfadiazine

as ordered.

Vital signstaken @ 9pm,

7/9/13:

Temp = 37.7

BP= 110/ 60

mm/Hg

RR= 28A

PR= 91

02sat = 95%
http://en.wikipedia.org/wiki/Anatomyhttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Osseous_tissuehttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Fasciahttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Fathttp://en.wikipedia.org/wiki/Synovial_membranehttp://en.wikipedia.org/wiki/Synovial_membranehttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Nervehttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Nervehttp://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Connective_tissuehttp://en.wikipedia.org/wiki/Synovial_membranehttp://en.wikipedia.org/wiki/Synovial_membranehttp://en.wikipedia.org/wiki/Fathttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Fibrous_connective_tissuehttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Fasciahttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Osseous_tissuehttp://en.wikipedia.org/wiki/Organ_(anatomy)http://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Anatomy


2/5


BSN 4 - 3 July 10, 2013

Patient: X

received

connected to

urine bag

noted c

yellowishoutput with

adequate

amount.

c bed soregrade 2 on the

lumbar area c

estimate 8

10 long

c 2 more bedsore grade 3

approximately

12 indiameter

(+) edemawith grade 2

pitting

Noted cdistended

abdomen

Hypotonicbowel sound

noted upon

auscultation

Initial Vitalsigns taken @

3pm, 7/9/13:

T= 39.6C, BP

= 100/50

mm/HG RR=

32 A cpm, PR

98 bpm, O2

Sat = 93%

are not connective

tissue).

Pressure on soft tissues

between bony

prominences

Compresses capillaries

& occludes blood flow

Pressure not relieved

Microthrombi

formation

+ occlusion in

capillaries & blood

flow

Formation of blister

Rupture of blister

Increase thefrequency of

turning

(turning q2).

Position the

client to stayoff the ulcer. If

there is no

turning surface

without a

pressure ulcer,

use a pressure

redistribution

bed & continue

turning the

client

Elevate heelsoff the bed by

using pillows

or heel

elevation botts.

in assessment.

To dispersepressure over

time or

decreasing

the tissue

load

Heel covers donot relieve

pressure, but

they can

reduce friction.


3/5


BSN 4 - 3 July 10, 2013

Patient: X

+ open wound

Source:

Johnson, J. Y.(2010).

Handbook for Brunner& Suddarth'stextbook

of medical-surgical

nursing.Philadelphia:

WoltersKluwer/Lippincott Williams& Wilkins

Maintain headof bed @ the

lowest

elevation, ifclient must

have the head

elevated to

prevent

aspiration,

reposition to

30 degree

lateral position.

Use seat

cushions &

assess sacral

ulcers daily.

Follow bodysubstance

isolation

precautions;

use clean

gloves & clean

dressing for

wound care.

Practicing

proper hand

washing before

& after wound

care.

To preventfurther

occurrence of

pressure ulcer.

To reduce riskof infection


4/5


BSN 4 - 3 July 10, 2013

Patient: X

Dependent/Collabor

ative:

Ensure adequatedietary intake.

Review dieticians

recommendations.

Prevent the ulcerfrom being

exposed to urine

& feces. Use

indwelling

catheters, bowel

containment

systems, & topical

creams or

dressings.

Supplement thediet with vitamins

& minerals..

Provide oralsupplementations,

tube-feedings or

hyperalimentation

To preventmalnutrition &

delayed

healing

To preventcontamination/

spread of

infection

To promotewound healing

on clients who

do not have

adequatecalories.

Pressureulcers cannot

heal in clients

with severe


5/5


BSN 4 - 3 July 10, 2013

Patient: X

to achieve positive

nitrogen balance.

Removedevitalized tissue

from the wound

bed, except in the

avascular tissue or

on the heels.

Began by

cleansing the ulcer

bed with normal

saline, then use

appropriate

technique fordebridement.

Once the ulcer is

free of devitalized

tissue, apply

dressing the keep

the wound bed

moist & the

surrounding skin

dry. Do not use

occlusive

dressings on ulcer.

malnutrition.

To promote fasterhealing & reduce

infection

Documents

NCP Impaired Skintissue Integrity