Sie sind auf Seite 1von 5

Art Christian M.

Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
Diagnosis Impaired Tissue Integrity related to prolonged immobilization secondary to spinal cord injury. Inference Skin is the primary defense of the body; it protects 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 tissue includes tendons, ligam ents, fascia, skin, fibrou s tissues, fat, and synovial membranes (which are connective tissue), and muscles, nerves an d blood vessels (which Planning After 8 hours of effective nursing intervention, patient will be able to: Manifest signs of comfort from wound Manifest signs of healing and reduction of pressure ulcers Vital signs within normal limits. Interventions Assess between folds 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 objective data of pressure ulcer (stage, length, width, depth, wound bed appearance, drainage & condition of periulcer tissue) Rationale Pressure ulcers under medical devices are commonly overlooked. Evaluation After 8 hours of effective nursing intervention, patient manifested:

Assessment Subjective: N/A due to patient can only mouth words when asked or when she needs something. Objective:

Received Sleeping but arousable c Nasogastric tube intact and patent for feeding(NPO temporarily) c endotracheal tube @ 22mm leveled connected to Mechanical Ventilatior c settings @ : Fi02 = 40% TV = 400ml IFR = 55 BUR = 16 18 AC mode c IVF 1L PNSS leveled @ 720cc, infusing @ 80cc/hr. c foley catheter

Reassessment of 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

Signs of comfort by being able to rest and sleep for long periods Manifest signs of healing by applying silver sulfadiazine as ordered. Vital signs taken @ 9pm, 7/9/13: Temp = 37.7 BP= 110/ 60 mm/Hg RR= 28A PR= 91 02sat = 95%

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
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 the frequency of turning (turning q2). Position the client to stay off the ulcer. If there is no turning surface without a pressure ulcer, use a pressure redistribution bed & continue turning the client Elevate heels off the bed by using pillows or heel elevation botts. To disperse pressure over time or decreasing the tissue load in assessment.

received connected to urine bag noted c yellowish output with adequate amount. c bed sore grade 2 on the lumbar area c estimate 8 10 long c 2 more bed sore grade 3 approximately 1 2 in diameter (+) edema with grade 2 pitting Noted c distended abdomen Hypotonic bowel sound noted upon auscultation Initial Vital signs taken @ 3pm, 7/9/13: T= 39.6C, BP = 100/50 mm/HG RR= 32 A cpm, PR 98 bpm, O2 Sat = 93%

Heel covers do not relieve pressure, but they can reduce friction.

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
+ open wound Maintain head of bed @ the lowest elevation, if client must have the head elevated to prevent aspiration, reposition to 30 degree lateral position. Use seat cushions & assess sacral ulcers daily. Follow body substance isolation precautions; use clean gloves & clean dressing for wound care. Practicing proper hand washing before & after wound care. To prevent further occurrence of pressure ulcer.

Source: Johnson, J. Y.(2010). Handbook for Brunner & Suddarth'stextbook of medical-surgical nursing.Philadelphia: WoltersKluwer/Lippinc ott Williams& Wilkins

To reduce risk of infection

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
Dependent/Collabor ative:

Ensure adequate dietary intake. Review dieticians recommendations. Prevent the ulcer from being exposed to urine & feces. Use indwelling catheters, bowel containment systems, & topical creams or dressings. Supplement the diet with vitamins & minerals..

To prevent malnutrition & delayed healing

To prevent contamination/ spread of infection

To promote wound healing on clients who do not have adequate calories.

Provide oral supplementations, tube-feedings or hyperalimentation

Pressure ulcers cannot heal in clients with severe

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
to achieve positive nitrogen balance. Remove devitalized 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 for debridement. 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 faster healing & reduce infection