NPR Document 31
Running head: NURSING PROCESS PAPER
Nursing Process Recording
Kimberly E. Fuller
Kent State University
11 October 2005
NPR Document 31
Kent State University N30040
Medical 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).
NPR Document 31
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):
NPR Document 31
KENT STATE UNIVERSITY
COLLEGE OF NURSING
DRUG INFORMATION
Date:
Patient Diagnosis: Stroke
Drug
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
Indications for Use
Side Effects
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.
Serious side effects include
arrhythmias, CHF, and StevensJohnson Syndrome. Another side
effect, less serious though, is peripheral
edema.
Nursing Responsibil
BP and pulse should be mon
periodically during therapy
nurse should assess for sign
such as, peripheral edema,
weight gain, jugular venous
and rales/crackles. Also, th
should monitor ECG contin
during administration and
signs of bradycardia and pr
hypotension immediately. T
be a sign of an arrhythmia.
Reason for giving this drug to this
client: Management of clients
HTN.
Drug-Drug interactions wit
NPR Document 31
Drug
Generic: lactulose
Trade: Cephulac, Cholac,
Constulose, Duphalac, Enulose,
Evalose, Heptalac, Kritalose,
Lactulose PSE, Portalac
Indications for Use
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.
Side Effects
Nursing Responsibil
Side effects include belching, cramps,
distention, flatulence, diarrhea, and
hyperglycemia in diabetic patients.
Bowel assessment should be
performed. The nurse shou
assess color, consistency, an
of stool produced. Lastly, t
should monitor glucose leve
serum electrolytes with chr
Severe side effects include hepatic
failure and hepatoxicity. Other side
effects include renal failure, rash,
urticaria.
Assess type, location, and in
prior to and 30-60minutes f
administration. If given for
signs of diaphoresis, tachyc
malaise. Lastly, hepatic, he
and renal function should b
Dose: 30mL
Frequency/Route: tiw via
enteral tube
Reason for giving this drug to this
client: Managements of clients
constipation.
Pharmacotherapeutic:
osmotics
Clinical: laxatives
Generic: acetaminophen
Trade: Tylenol
Dose: 650mg
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.
Frequency/Route: tid via
enteral tube
Pharmacotherapeutic:
Clinical: antipyretics, nonopioid analgesics.
Reason for giving this drug to this
client: Management of clients
pain.
Drug-Drug interactions wit
NPR Document 31
Drug
Generic: oxycodone
Trade: Endocodone, M-Oxy,
Oxycontin, OxyFAST, OxyIR,
Percolone, Roxicodone SR
Indications for Use
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.
Side Effects
A serious side effect is respiratory
depression. Other side effects include
confusion, sedation, and constipation.
Nursing Responsibil
The nurse should perform a
assessment. The nurse shou
perform a bowel assessmen
monitor BP, pulse, and RR.
may also want to watch pla
amylase and lipase levels.
Dose: 5mg
Frequency/Route: q.d. via
enteral tube
Reason for giving this drug to this
client: Management of clients
pain.
Pharmacotherapeutic: opioid
agonists, opioid
agonists/nonopiod analgesic
combinations
Drug-drug interactions with
and hypnotics.
Clinical: opioid analgesic
Generic: risperidone
General Use: May act by
antagonizing dopamaine and
Trade: Risperdal, Risperdal M- serotonin in the CNS.
TAB
Consequently, this drug results in
decreased symptoms of psychosis.
Dose: 1.5mg
Reason for giving this drug to this
Frequency/Route: b.i.d. via
client: Management of clients
enteral tube
schizophrenia.
Pharmacotherapeutic:
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 t
mental status and assess for
changes. Also, the nurse sh
monitor for onset of extrap
side effects, tardive diskines
development of neoroleptic
syndrome. Lastly, the nurs
know that this drug can cau
increased serum prolactin,
ALT. Risperidone can also
anemia, thrombocytopenia,
leukocytosis, and leucopeni
Clinical: antipsychotic
Drug-Drug interactions wit
and antacids.
NPR Document 31
Drug
Generic: quetiapine
Trade: Seroquel
Dose: 150mg
Frequency/Route: q.d. at
8pm/hs via enteral tube
Pharmacotherapeutic:
Indications for Use
General Use: Probably acts by
serving as an antagonist of
dopamine and serotonin thereby
decreasing manifestation of
psychoses.
Side Effects
Two serious side effects are neuroleptic
malignant syndrome and seizures.
Other side effects include dizziness and
weight gain.
Reason for giving this drug to this
client: Management of client’s
schizophrenia symptoms.
Nursing Responsibil
The nurse should monitor p
mental status and monitor f
changes. Also, the nurse sho
monitor for onset of extrap
side effects, tardive diskines
development of neoroleptic
syndrome. Seroquel can als
anemia, thrombocytopenia,
leukocytosis, and leucopeni
Clinical: antipsychotic
Drug-Drug interactions wit
analgesics ad sedatives/hyp
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 StevensJohnson Syndrome. Other side effects
include dizziness, drowsiness, headache,
insomnia, abdominal pain, diarrhea,
and nausea (Deglin & Vallerand, 2005).
The nurse should assess the
signs and symptoms of anap
and infection. The nurse sh
be aware that this drug can
hyperglycemia, hyperlipide
increased WBC count, incr
serum calcium, chloride, alb
globulin. Decreases in gluc
RBC’s, neutophils, eosinoph
basophils can occur (Deglin
Vallerand, 2005).
NPR Document 31
Drug
Generic: metoclopramide
Trade: Clopra, Octamide,
Octamide-PFS, Reclomide,
Reglan
Dose: 10mg (10ml)
Frequency/Route: q.i.d. via
enteral tube
Pharmacotherapeutic:
Clinical: antiemetics
Generic: ipatropium
Trade: Atrovent
Dose: 1UD-0.02% inh. sol.
Frequency/Route: q.i.d via
aerosol PRN
Pharmacotherapeutic: enzyme
inhibitors
Clinical: antineoplastics
Indications for Use
Side Effects
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).
Symptoms include drowsiness,
extrapyramidal reactions, and
restlessness (Deglin & Vallerand, 2005).
Reason for giving this drug to this
client: Management of client’s
N/V.
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
Nursing Responsibil
The nurse should assess the
N/V, abdominal distention,
sounds before and after,
extrapyramidal side effects,
dyskinesia, and for signs of
Also, the nurse should know
drug could alter hepatic fun
results.
Drug-Drug interactions wit
depressants, opioid analges
sedative/hypnotics (Deglin &
Vallerand, 2005).
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
atropine and belladonna alk
Assess respiratory status be
after administration (Deglin
Vallerand, 2005).
NPR Document 31
Drug
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
Indications for Use
General Use: Binds to beta2adrenergic 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
Side effects include nervousness,
restlessness, tremor, chest pain, and
palpitations (Deglin & Vallerand,
2005).
Nursing Responsibil
Assess lung sounds, pulse, a
before and after administra
nurse should also periodica
pulmonary function tests an
for wheezing. Lastly, the nu
be aware that this drug cou
decrease in serum potassium
& Vallerand, 2005).
NPR Document 31
Drug
Generic: sennosides
Trade: Black-Draught, ExLax, Ex-Lax Chocolated,
Fletchers’ Castoria, Maximum
Relief Ex-Lax, Sena-Gen,
Senexon, Senokot,
SenokotXTRA.
Dose: 2tsps (10ml)
Indications for Use
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).
Side Effects
Nursing Responsibil
Common symptoms include cramping
and diarrhea (Deglin & Vallerand,
2005).
Nurse should perform a bow
assessment and assess the c
consistency, and amount of
(Deglin & Vallerand, 2005)
Severe side effects include hepatic
failure and hepatoxicity. Other side
effects include renal failure, rash,
urticaria (Deglin & Vallerand, 2005).
Assess type, location, and in
prior to and 30-60minutes f
administration. If given for
signs of diaphoresis, tachyc
malaise. Lastly, hepatic, he
and renal function should b
(Deglin & Vallerand, 2005)
Reason for giving this drug to this
client: Management of client’s
chronic constipation.
Frequency/Route: q.d. via
enteral tube
Pharmacotherapeutic:
stimulant laxatives
Clinical: laxatives
Generic: acetaminophen
Trade: Tylenol
Dose: 650mg
Frequency/Route: q6h via
enteral tube PRN
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).
Pharmacotherapeutic:
Clinical: antipyretics, nonopioid analgesics.
Reason for giving this drug to this
client: Management of clients
pain.
NPR Document 31
Drug
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
Indications for Use
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.
Side Effects
A serious side effect is respiratory
depression. Other side effects include
confusion, sedation, and constipation
(Deglin & Vallerand, 2005).
Nursing Responsibil
The nurse should perform a
assessment. The nurse shou
perform a bowel assessmen
monitor BP, pulse, and RR.
may also want to watch pla
amylase and lipase levels (D
Vallerand, 2005).
NPR Document 31
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 4-18
Balance
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
11.514.5%
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
NPR Document 31
STUDENT NAME: Kimberly Fuller
DATABASE
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.
NPR Document 31
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.
NPR Document 31
COGNITIVE/PERCEPTUAL
(alertness, memory, neurologic,
sensory)
ROLE/RELATIONSHIP
(Family response communication;
response, visitation)
SELF-PERCEPTION/
SELF-CONCEPT (Appearance,
behavior, mood)
Client severely aphasic.
Client severely aphasic.
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.
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.
Client either appeared sad or had an expressionless
look on her face while she was in bed.
NPR Document 31
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.
NPR Document 31
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
NPR Document 31
Subjective Data
Client severely aphasic and unable to
provide any subjective data.
Objective Data
Client has development of contractures
in both hands and feet.
Client completely immobile.
Client incontinent of urine and stool.
Client severely aphasic.
Data Group (include at least 5). Indicate
source of data.
1. Stroke (Diagnoses Tab in ECS, 10/14/2004).
2.
Dysphagia (Physicians Progress Notes, 9/1/2005).
3.
Client incontinent of urine and stool (Objective data).
4.
Client severely aphasic (Objective Data).
5.
Client has development of contractures in hands and feet
(Objective Data).
Indirect Data
Diagnosis of stroke.
Diagnosis of dysphagia.
Interpretation with documentation
“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).
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).
“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).
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).
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).
NPR Document 31
NANDA
Nursing Diagnosis: 1: Risk for
impaired skin integrity r/t
immobility.
NOC
NOC (Nursing Outcome Classification:
Tissue Integrity: Skin and Mucous
Membranes
AEB: Altered sensation,
alteration in nutritional status,
incontinence, extremes of age,
and inability to move.
Definition (source): Structural intactness
and normal physiological function of skin and
mucous membranes. (Moorhead, p.544)
Definition (source): At risk for
skin being adversely, altered.
(NANDA, 2005)
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.
NIC
Intervention: A. Pressure mana
(Dochterman, 581)
Definition (source): Minimizin
parts. (Dochterman, 581)
Intervention: B. Skin surveilla
p.657)
Definition (source): Collection
patient data to maintain skin an m
integrity. (Dochterman, p.657)
LTG: Client will remain at a level 5 for skin
integrity throughout her stay Jennings
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)
Activity 3A: Turn/position clie
schedule. (Dochterman, p.581)
Nursing Order: Perform skin assessment q
shift during AM care while bathing.
Nursing Order: Reposition clie
wheelchair every 2-3hours.
Rationale: Nurses must routinely assess the
skin to look for primary or initial wounds that
may develop (Potter & Perry, 687).
Rationale: To prevent skin brea
clients should be turned every 2
Perry, p.1431).
Evaluation: During AM care found the skin
to be intact and no evidence of breakdown
was noted.
Evaluation: Repositioned clien
Client remained comfortable.
NPR Document 31
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).
Activity 3B: Inspect clothing fo
(Dochterman, p.67).
Nursing Order: Change clients brief as
necessary and assess the perineal/rectal areas
for evidence of breakdown.
Nursing Order: Inspect client’
note any tightness and possible b
area.
Rationale: The client with fecal incontinence
is at risk for skin breakdown when fecal
contents remain on the skin (Potter & Perry,
1416).
Rationale: With the thinning of
skin is easily injured (Hogstel &
Evaluation: Change clients brief as needed.
Client had one large watery stool.
Evaluation: Inspected patients c
and noted that it was twisted aro
neck due to her position. I fixed
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
for LTG.
NPR Document 31
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