LAGUARDIA COMMUNITY COLLEGE
City University of New York
SCR 290
NURSING PROCESS TOOL
Student Name: Louise Margaret Tomas
Clinical Date: 03/16/2009
Biographical Data : Client’s Initials: T.C
Room: D32-04 Sex: M Age: 33 years old
Religion: Not Known Occupation: Not Known
Cultural/Ethnic Background: African American
Admitting Date: 12/12/2008
Reason for Admission: Respiratory Failure; s/p stab
wound to chest and abdomen
Data - Label S for Subjective, O for Objective
R
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Admitting Diagnosis : Respiratory Failure;
Secondary Diagnosis: Anoxic Encephalopathy
Surgical Procedure: Not Applicable
Date: Not Applicable
Health History:
Data Analysis (Provide reference)
Nursing Diagnosis
A. Rest:(Usual, alterations assoc. with illness/hospitalization)
Hours of sleep each night- Unable to assess since client is in
vegetative state. (O)
.Immobility
Difficulty falling asleep; early awakening; nap during day;
manifestations of sleep deprivation- Unable to assess since client A client’s impaired mobility due to systemic disease, and or, aging
is in vegetative state. (O)
may lead to further physical deterioration. Each joint of the body Risk for Disuse syndrome r/t
Assistive measures: warm milk, medication, etc. – Unable to has a range of motion; if the range becomes limited the function of immobility, decreased muscle
assess since client is in vegetative state. (O)
the joint becomes limited. Painful deformities and permanent
strength, decreased range of joint
physical limitations may develop (Brunner 165).
B. Activity
Degree of mobility of all joints; condition of joints Ability to flex and extend limbs against graduated resistanceHand grasp- bilateral; coordinationAbility to stand, assistance needed; posture, gait, balanceClient is completely dependant. (O)
Assistance needed to transfer, stand, walk and use of assistive
devices (cane, crutches, walker, wheelchair)- Client is bed
ridden and needs complete assistance when being transferred. (O)
Ability to perform ADL- Client is completely dependant in
performing ADLs. (O)
Restrictions imposed by health problems/therapeutic
modalitiesOther factors that may affect mobility – Client is ventilator
dependant and is in a vegetative state. (O)
motion
The aging process and lack of mobility increases the risk of the
development of progressive bone degenerative diseases, such as
osteoporosis. Client’s who are unable to ambulate or perform
weight bearing exercises, increase the risk for spontaneous
fractures due to weak, brittle bones. Without the stress of weight
bearing activity, the bones are subject to demineralization. Bones
become spongy and may gradually deform and fracture easily.
Unused muscles lose most of their strength and atrophy.
When muscles are not able to expand and contract eventually a
contracture forms limiting joint mobility. Without mobility
collagen at the joints becomes ankylosed (Kozier 1068)
Muscles diminish and lose strength, flexibility and endurance with
increasing age and decreased activity. (Brunner 195)
Bed Rest
It is an intervention that restricts client to bed for therapeutic
reasons. The lack of physical activity is associated with
skeletomascular and other body systems changes.(P&Pp1427)
Limited ROM:
Limited ROM may indicate inflammation such as arthritis, fluid in
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the joint, altered nerve supply, or contractures. (P&Pp938)
A joint contracture is an abnormal and possibly permanent
condition characterized by fixation of the joint. It is caused by
disuse, atrophy, and shortening of the muscle fibers. When a
contracture occurs, the joint can’t obtain full ROM. Upper and
lower extremity contractures significantly reduce functional
performance in older adults and are results of the immobility.
(P&Pp1430)
E
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A. Urinary
Voiding (Usual, alterations associated with illness and
hospitalization)Frequency, urgency, dysuriaUrine: quantity, color, clarity, odor, Sp. G.Lab: urinalysis , C/S , BUN (norm= ); creatinine
(norm= );
Assistive devices (indwelling, external catheter) Structural
adaptations; urinary diversions- Client has a Texas (external)
catheter. (O)
Retention/bladder distention- No bladder distention is noted. (O)
Other factors that may affect normal urinary elimination –
Urinary incontinence – It is involuntary loss of urine because of Risk for impaired skin integrity r/t
neuromuscular impairments of pelvic muscle tone ,age ,or unstable urinary incontinence.
urthera. Continued episodes of incontinence create the potential
risk for skin breakdown. The urine remain in contact with skin
Self-care deficit: Toileting r/t
cause skin maceration and breakdown .( PP1329)
neuromuscular impairment aeb:
Pt. is urinary incontinent.
Immobilty- The clients urinary eliminatin is altered by
immobility .In the upright position ,the gravitational forces help to Risk for constipation r/t
eliminate the urine .When the client is recumbent or flat ,urine
insufficient physical activity and
formed by the kidney must enter the bladder unaided .Because the medications.
peristaltic contractions of the ureters are insufficient to overcome
gravity ,the renal pelvis may fill before urine enters the
urether.(PP1430)
B. Bowel
Evacuation patterns (Usual, alterations associated with illness
& hospitalization)Last BM- Client is incontinent. (O)
Stool: quality, color, consistency, presence of blood, mucusAssistive measures: laxative, enemas, suppositoriesBowel soundsAbdomen: distension, firmness, tenderness- No abdominal
distension noted when inspected; abdomen is firm and soft; no
tenderness is observed upon palpation. (O)
Structural adaptations; Ostomies- Client has no ostomy. (O)
Other factors that may affect normal bowel elimination –
.
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A
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Affect: withdrawn, sad, cheerful, angry, blank expressionAbility to communicate (verbal & non-verbal) – Client is in
vegetative state but was observed to have “smiled” when patient
care and wound dressing treatment was finished. (O)
Barriers to communication: language, facility, aphasia,
tracheotomy/E.T. tube, perceptual impairments,
developmental disorders, etc.- Client has a tracheotomy
Primary language /ability in English- Primary language was
listed as English. (O)
Understanding of health status/reason for hospitalizationUnable to assess since client is in vegetative state.
Any manifestation of anxiety/describe behavior- Unable to
assess since client is in vegetative state. (O)
Coping mechanisms used- Unable to assess since client is in
vegetative state. (O)
Self concept/body image; self esteem- Unable to assess since
client is in vegetative state. (O)
Risk for situational low selfSelf Concept
esteem r/t illness, hospitalization
Self-concept is a mental self-image of strengths and weaknesses in and lack of familial support.
all aspects of personality. Self-concept depends in part on body
image and roles. The impact of illness on self-concept of the client
is very significant. (P.&P.)
Family or significant others are crucial factors in an individual’s
adjustment to a crisis therefore the family members have potential
to be primary force for coping. If there is no family coping patient
is even farther away from the restore. (P.&P.p. 146)
Hospitalization:
Hospitalized client can be at risk for sensory alterations due to
exposure to environmental stimuli or change in sensory input.
(P.&P.p.151)
Family constellation/role within family; living arrangements;
significant othersStage of growth and development: achievement of
developmental tasks; give evidence- Unable to assess since
client is in vegetative state. (O)
Family situation: recent changes or crises- Client’s aunt stated
“he began drinking a lot when his mother died mid last year.” (O)
Hobbies- Unable to assess since client was in vegetative state and it
was not mentioned by aunt during client’s admission interview. (O)
Level of education- Client’s aunt said “He’s a High School
Graduate”. (O)
Cultural/ethnic influences- Client is African American but it
does not influence.
Formal religion; spiritual needs- None
Economic situation (socioeconomic status)- Unapllicable.
Occupation: Client’s aunt stated that client was incarcerated in
“the regular jail system” for an unspecified amount of time. (O)
specific roleSupport systems: church groups, AA, etc.- Not Applicable.
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Patterns of sexual function (alterations associated with
illness)- Unable to assess since client is in vegetative state.
Menstrual history and pattern- Not Applicable.
Reproductive history/disorders; menopause history- Not
Applicable.
Urethral, vaginal discharge- Not Applicable.
Allergies: Manifestation- Client is allergic to Penicillin. (O)
Stage of consciousness: alert, confused, drowsy, lethargic,
S stuporous, comatose- Client is a vegetative state. (O)
A Orientation: person, place, time- Client is not orientated to time/
F person/ place. (O)
E Ability to recognize & respond to environmental hazardsT Memory: immediate, recent, remote- Unable to assess since
Y client is in vegetative state. (O)
Ability to concentrate, problem solve- Unable to assess since
client is in vegetative state. (O)
Pupillary response: PERRLA-
.
.
Senses: taste, touch, smell, pain, sight, hearingAssistive devices: glasses, lens, hearing aid- No assistive devices
were noted. (O)
Symmetry of facial expressions, tongue, smile- Client’s face is
symetical. (O)
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Y
Condition of hair, nails, mucous membranes of mouth, nose,
and conjunctiva, tongue- Client’s mucous membranes are pink
and intact. (O)
Condition of skin: describe wounds, stages of decubiti, I.V.
sites, dressings, scars, rashes, nodules, ecchymosisClient has a peripheral IV in his R forearm. The site was clean
with no sign of infection; phlebitis or infiltration. (O)
Client has the following scars:
1. scar above his umbilicus.
2. scar to the R of his umbilicus.
3. scar located on the RL quadrant of his abdomen.
4. scar located to the L of his umbilicus. (O)
Client has the following pressure ulcers:
Risk for nosocomial infection:
Risk for infection r/t to invasive
procedure (peripheral IV)
A hospital is one of the most likely places for acquiring an
infection because it harbors a high population of virulent
strains of microorganisms that may be resistant to antibiotics.
The number of health care employees having direct contact with
a client, the type and number of invasive procedures, the therapy
received, and the length of hospitalization influence the risk for
infection.
(Brunner & Suddarth pg. 2475)
Intravenous Infusions:
There are numerous hazards that a pt. can encounter when
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1. Un-stagable Left ear pressure ulcer
2. Un-stagable Left ankle pressure ulcer
3. Stage 3 Right buttock pressure ulcer
4. Unstagable occipital pressure ulcer
5. Stage 1 Left buttock pressure ulcer
6. Stage 3 Left lower posterior leg pressure ulcer.
Other factors that may affect skin integrity – Client is
S immobile. (O)
A
F Condition of breasts: symmetry, contour, puckering, nipple
E discharge, gynecomastia- Client’s nipples are symmetrical. (O)
T Comfort status: itching, burning, nausea, hunger, pain
Y (character, location, onset, duration, relief measures)Other factors that may affect comfort status –
IV type and rate, medication added- 20mL/ hour to Keep Vein
Open
Fluid status: IV type and rate, medication addedI&O: Date: Intake: IV: PO: ;
Output: Urine: 300mL / 8 Hours Other: ;
Date: Intake: IV PO ;
Output: Urine: Other:
Skin turgor, rapid weight gain or loss, condition of mucous
S membranes of mouthA Client’s skin turgor was good; elastic; no rapid weight gain was noted in
F chart; and the oral mucosa was pink. (O)
E Other factors that may affect fluid and electrolyte status T Lab data and Diagnostic tests:
Y Lab: electrolytes , WBC (norm=); culture reports , total
cholesterol (norm= ); LDL (norm= ); HDL (norm= );
triglycerides (norm= ); liver function test, etc.-
receiving IV therapy due to the introduction of
microorganisms. These include local complications like phlebitis,
infiltration, hematoma or clotting of the needle and systemic
complications which are more serious like infections.
(Brunner & Suddarth pg. 290)
Latrogenic infections are type of nosocomial infection resulting
form diagnostic or therapeutic procedure. (PP- 779
Impaired skin integrity r/t
immobility aeb pressure ulcers.
Pressure ulcer formation and immobility.
The direct effect of pressure on the skin by immobility is
compounded by the changes in metabolism that accompany
immobility. Any break in the skin’s integrity is difficult to treat in
the immobilized client. Preventive a pressure ulcer is much less
expansive than treating one. Thus immobility is a major risk for
pressure ulcers and preventing nursing interventions are
imperative. (PP 1486)
Other significant lab data (include significant data not
specified, such as serum levels of drugs, endocrine testes, etc.)
Diagnostic tests results (scans, MRI, echo, etc.) Risks Associated with Diagnostic and Therapeutic Modalities
(Some examples include anticipation of common problems
identified with: perioperative care, use of restraints,
nasogastric tube feeding, blood therapy, total parenteral
nutrition, chest tubes, central lines, surgical procedures, etc.)V.B.
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Body temperature patterns x 2 days03/15/2009: 100.3 F
03/16/2009: 97.6 F
Recent exposure to infections- Client is hospitalized. (O)
Manifestations of active infectionImmunization: inquire about status including TD, Hepatitis B,
Flu, and Pneumococcal- Not assessed,
Medications: major risks associated with side
effects/interaction- Please see attached medication list.
Alcohol and/or unprescribed drug use: Unable to assess since
client is in a vegetative state.
Discharge Planning
1. Where will the client be going after discharge: No current
discharge plan is in client’s chart. Client may be a long-term care
client (O)
2. If returning to home, inquire about home environment:
adequate space, stairs to climb, cooking facilities, hazards.: Not
Applicable.
3. Ability to manage health problem(s): knowledge base,
motivation, constraints, role of significant others, teaching
needs, affordability of medications, supplies and equipment.:
Not Applicable.
4. Medical follow-up: understands need for, transportation to
PMD, clinic, and labs. : Not Applicable.
5. Anticipated need for referral: Social Worker, Visiting
Nurse, and other Home Care Services.: Not Applicable.
O Chest pain, describe- None observed. (O)
X Nails, lips skin, mucus membranes: color/temperature- Client’s Yellowing of Nails
Hypoxemic Hypoxia is one of four types of Hypoxia. Some of the
Y lower extremity nails (toe nails) observed to be thick and yellow in
causes of hypoxemic hypoxia are pulmonary diffusion deficits,
G color.(O)
hypoventilation and pulmonary embolism. Lone term hypoxic
E Capillary refill: upper extremities Normal: <2 seconds, lower
conditions can lead to clubbing, thickening and yellowing of the
N extremities Normal: <2seconds:
nails, pale lips and mucous membranes, and tissue damage due to
A Pulse - rate, rhythm, quality (rate pattern x 2 days)decreased oxygen supply. (Brunner 600-601)
T 03/15/2009: 101
I 03/16/2009: 96
O Compare apical / radial pulsesN Peripheral pulses: presence, volume, compare bilaterally
(brachial, radial, femoral, popliteal, posterior tibia, dorsal
pedis) Homan's sign- negative (O)
Ineffective breathing pattern r/t
decreased function of the
respiratory system AEB need for
supplemental oxygen O2; need
for mechanical ventilation.
Impaired gas exchange r/t
ventilation AEB
clubbing/yellowing of all nail
beds, need for supplemental
oxygen.
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Edema: degree and location/measure abdominal girth p.r.nDistention of neck veins- No neck distension observed. (O)
O Blood pressure pattern x 2 daysX 03/15/2009: 91/52
Y 03/16/2009: 96/51
G pulse pressure: Client’s pulse and present and bounding (O).
E Other factors that may effect the cardiovascular system N Activity toleranceA OrthopneaT Shape of chest- No evidence of barreling of the width of the chest
I observed. (O)
O Respirations - rate, rhythm, depth, patterns, use of accessory
N muscles, symmetry of chest movements, rate pattern x 2 days03/15/2009: 10
03/16/2009: 12
Breath sounds: clear, course, crackling, wheezing- None
observed. (O)
Location of adventitious sounds- None present. (O)
Cough: frequent, infrequent, dry, loose, barking, productive,
etc.Sputum: color, tenacity, amount, colorAssistive measures: oxygen therapy (kind), tracheotomy,
ventilator with E.T. tube, etc.- Client has tracheotomy and is
ventilator dependant. (O)
History of smoking tobacco/marijuana: Client’s aunt said “he
has a smoked marijuana.” (O) amount, duration- Duration was not
Breathing pattern ineffective r/t
artificial airway, immobility aeb
presence of secretions resting in
the fowlers position.
noted. (O)
Other factors that may affect the respiratory system –
Lab: RBC count 36.1 (norm= 4.7-6.10 ); Hgb. 10.4 (norm=
14.0-18.0 ); Hct. (norm= ); Plat. 641 (norm= 130-400 );
ABG's , cardiac enzymes , PT (norm= ); APPT (norm= );
INR (norm= ); Guaiac Tests : Negative for occult blood.
Pulse oximetry results ; EKG report ; chest x-ray/lung scans ;
pulmonary function tests:.
General appearance: muscular, wasted, emaciated, obese, well
nourished- Client is well nourished. (O)
Height and weight patterns of gain or lossN Weight: compare current weight with ideal weightV.B.
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U
BMI Categories:
T
R
 Underweight = (Values)
I
T
 Normal weight = (Values)
I
 Overweight = (Values)
O
N

Obesity = (Values)
Immobility:
Immobilty disrupts normal metabolic functioning of the GI system
therefore decrease in metabolism of carbohydrates fats and protein
occurs .It also causes fluid electrolyte and calcium imbalances.(PP
1428)
Condition of teeth & gums, ability to chew and swallow- Client
has full set (upper and lower) of adult teeth. (O).
Usual eating patterns: describe the patient’s usual diet for
breakfast, lunch and dinner on a week day and on a weekend
day; identify usual number of servings of CHO, protein, milk,
vegetables, fruits and fats on a regular day and frequency of
intake of fast foods, fried foods, deserts, etcClient is on a full liquid diet given via his gastrostomy tube;
client’s diet is as follows: 2 Cal HN given with 125mL of water at
80 mL over 6 hours; flushed with 150 mL water.
N
U
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O
N
Caloric intake: 475 calories/ can
Total Daily Calories: 1820 calories.(O)
Intake of caffeine, alcohol, sodium, processed foods, fiber- Not
applicable.
Cultural/religious preferences- Not Applicable.
Alterations in eating patterns associated with illness &
hospitalizationDiet ordered/knowledge of/complianceClient is on a full liquid diet given via his gastrostomy tube;
client’s diet is as follows: 2 Cal HN given with 125mL of water at
80 mL over 6 hours; flushed with 150 mL water. (O)
When a person is immobile, the muscles of the body are not being Imbalanced nutrition: less than
used. Unused muscles atrophy (decrease in size). As a result, the body requirements r/t immobility
body may not require as much protein and other nutrients, causing aeb low muscle mass, client
an imbalance in nutrition as excess nutrients are eliminated and not receiving 1820 calories daily; less
used. (K&E, 1068, 1173)
than what is needed.
The normal daily liquid and calorie requirements for adults age 18
and up are 2200-2700 mL and 2000-2500 calories. (K&E, 1356)
IV Medlock
The goal of IV Medlock is to provide an open and available
parenteral route emergency fluid administration to correct or
prevent fluid and electrolyte disturbances. It allows for direct
access to the vascular system, permitting infusion of continuous
fluids over a period of time. IV fluid therapy must be continuously
regulated because of continual changes in the client’s fluid and
electrolyte balance.
Appetite: assess usual intake and the last 2 days(Brunner & Suddarth pg. 351)
Lab: total protein , serum albumin ; also consider
relationship of Hgb. to nutritional statusGlucose levels – blood – Not in chart urine glucose Not in
chart , acetone in urine: Not in chart.
Assistive measures for nutrition (i.e. tube feedings, TPN, etc.)Are current nutritional needs being met in terms of calories,
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protein, vitamin, calcium, etc. Provide objective data to
support your decision.- Client has a gastrostomy tube in place to
help supplement his dietary needs. (O)
If feeding by nasogastric, gastrostomy tubes or TPN: estimate
caloric intake for 24 hoursTotal Daily Calories: 1820 calories
Note
In all categories include significant data of patient’s condition
on admission including admission signs and symptoms; initial
results of diagnostic tests, lab data, procedures and therapeutic
regimen implemented initially and not yet discussed.
Describe pertinent health and family history, and life style that
may have affected the patient’s health status # 1 Priority Nursing Diagnosis
Outcomes
Impaired gas exchange r/t mechanical ventilation AEB Client will:
1. demonstrate improved ventilation and
clubbing/yellowing of all nail beds, need for
adequate oxygenation aeb blood gas levels
supplemental oxygen.
within normal parameters for this client q
shift.
2. maintain clear lung fields and remains free
of signs of respiratory distress q shift.
Implementation
Monitor respiratory rate, depth, and effort,
including use of accessory muscles, nasal flaring,
and abnormal breathing patterns. Increased
respiratory rate, use of accessory muscles, nasal
flaring, abdominal breathing, and a look of panic in
the client's eyes may be seen with hypoxia
2. Monitor oxygen saturation continuously by pulse
oximetry. Note blood gas results as available. An
oxygen saturation of less than 90 (normal, 95 to
100) or a PaO2 of less than 80 mm Hg (normal, 80
to 100 mm Hg) indicates significant oxygenation
problems (Clark, Giuliano & Chen, 2006). The goal
of inpatient therapy for the client with COPD is to
maintain the oxygen saturation greater than 90
and PaO2 at or above 80 mm Hg to maintain
cellular oxygenation (Celli, MacNee & ATS/ERS
Task Force, 2004).
1.
3.
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Observe for cyanosis of the skin; especially note color
of the tongue and oral mucous membranes. Central
cyanosis of the tongue and oral mucosa is indicative of
serious hypoxia and is a medical emergency. Peripheral
cyanosis in the extremities may or may not be serious
(Kasper, 2005).
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4.
Position clients in semi-Fowler's position, with an
upright posture at 45 degrees if possible. EB: Research
done on clients on a ventilator demonstrated that being
in a 45-degree upright position increased oxygenation
and ventilation (Speelberg & Van Beers, 2003). In a
mechanically ventilated client, there is a decreased
incidence of pneumonia if the client is positioned at a
45-degree semirecumbent position as opposed to a
supine position (Seckel, 2007).
5.
Turn the client every 2 hours. Monitor mixed
venous oxygen saturation closely after turning. If it
drops below 10 or fails to return to baseline
promptly, return the client to the supine position
and evaluate oxygen status. If the client does not
tolerate turning, consider use of a kinetic bed that
rotates the client from side to side in a turn of at
least 40 degrees. EBN: Use of the kinetic bed was
shown to decrease development of atelectasis and
ventilator-associated pneumonia in critically ill
clients (Ahrens et al, 2004). Rotational therapy
may decrease the incidence of pneumonia but has
little affect on mortality rates, number of days on
ventilator, or number of days in the intensive care
unit (Goldhill et al, 2007).
6.
# 2 Priority Nursing Diagnosis
Impaired skin integrity r/t immobility aeb pressure
ulcers.
Outcomes
Client will:

Regain integrity of skin surface

Report any altered sensation
or pain at site of skin impairment

Demonstrate understanding
of plan to heal skin and prevent
reinjury

Describe measures to
protect and heal the skin and to
care for any skin lesion
Implementation

Assess site of skin impairment and
determine cause (e.g., acute or chronic wound,
burn, dermatological lesion, pressure ulcer,
skin tear). EB: The cause of the wound must
be determined before appropriate interventions
can be implemented. This will provide the basis
for additional testing and evaluation to start the
assessment process (Baranoski & Ayello,
2003).

Determine that skin impairment involves
skin damage only (e.g., partial-thickness
wound, stage I or stage II pressure ulcer). The
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following classification system is for pressure
ulcers:
Stage I: Observable pressure-related
alteration of intact skin with indicators
as compared with the adjacent or
opposite area on the body that may
include changes in one or more of the
following: skin temperature (warmth or
coolness), tissue consistency (firm or
boggy feel), and/or sensation (pain,
itching). The ulcer appears as a defined
area of persistent redness in lightly
pigmented skin, whereas in darker skin
tones, the ulcer may appear with
persistent red, blue, or purple hues
(National Pressure Ulcer Advisory
Panel NPUAP, 1998).
Stage II: Partial-thickness skin loss
involving epidermis or dermis superficial
ulcer that appears as an abrasion,
blister, or shallow crater (NPUAP,
1998).
NOTE: For wounds deeper into subcutaneous
tissue, muscle, or bone (stage III or stage IV
pressure ulcers), see the care plan for
Impaired Tissue integrity.

Monitor site of skin impairment at least
once a day for color changes, redness,
swelling, warmth, pain, or other signs of
infection. Determine whether the client is
experiencing changes in sensation or pain. Pay
special attention to high-risk areas such as
bony prominences, skinfolds, the sacrum, and
heels. Systematic inspection can identify
impending problems early (Ayello & Braden,
2002).

Monitor the client's skin care practices,
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
noting type of soap or other cleansing agents
used, temperature of water, and frequency of
skin cleansing.
Individualize plan according to the client's skin
condition, needs, and preferences. EBN: Avoid
harsh cleansing agents, hot water, extreme
friction or force, or cleansing too frequently
(Panel for the Prediction and Prevention of
Pressure Ulcers in Adults, 1992; Wound,
Ostomy, and Continence Nurses Society
WOCN 2003).

Monitor the client's continence status, and
minimize exposure of skin impairment and
other areas of moisture from incontinence,
perspiration, or wound drainage. EBN:
Moisture from incontinence contributes to
pressure ulcer development by macerating the
skin (WOCN, 2003).

If the client is incontinent, implement an
incontinence management plan to prevent
exposure to chemicals in urine and stool that
can strip or erode the skin. Refer to a
continence care specialist, urologist, or
gastroenterologist for incontinence assessment
(WOCN, 2003). EB: Implementing an
incontinence prevention plan with the use of a
skin protectant or a cleanser protectant can
significantly decrease skin breakdown and
pressure ulcer formation (Clever et al, 2003;
Fantl et al, 1996; Warshaw et al, 2002).

For clients with limited mobility, use a risk
assessment tool to systematically assess
immobility-related risk factors (Ayello & Braden,
2002). A validated risk assessment tool such
as the Norton or Braden scale should be used
to identify clients at risk for immobility-related
skin breakdown (Ayello & Braden, 2002). EB:
Targeting variables (such as age and Braden
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Scale Risk Category) can focus assessment on
particular risk factors (e.g., pressure) and help
guide the plan of prevention and care (Panel
for the Prediction and Prevention of Pressure
Ulcers in Adults, 1992; WOCN, 2003; Young et
al, 2002).

Do not position the client on site of skin
impairment. If consistent with overall client
management goals, turn and position the client
at least every 2 hours. Transfer the client with
care to protect against the adverse effects of
external mechanical forces such as pressure,
friction, and shear.

Evaluate for use of specialty mattresses,
beds, or devices as appropriate. Maintain the
head of the bed at the lowest possible degree
of elevation to reduce shear and friction, and
use lift devices, pillows, foam wedges, and
pressure-reducing devices in the bed (WOCN
Clinical Practice Guideline series 2, 2003;
Panel for the Prediction and Prevention of
Pressure Ulcers in Adults, 1992).
Implement a written treatment plan for topical
treatment of the site of skin impairment. A
written plan ensures consistency in care and
documentation (Baranoski & Ayello, 2003;
Maklebust & Sieggreen, 2001).



Select a topical treatment that will maintain
a moist wound-healing environment and that is
balanced with the need to absorb exudate.
EBN: Choose dressings that provide a moist
environment, keep periwound skin dry, and
control exudate and eliminate dead space
(WOCN, 2003).
Avoid massaging around the site of skin
impairment and over bony prominences.
Research suggests that massage may lead to
deep-tissue trauma (Panel for the Prediction
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

and Prevention of Pressure Ulcers in Adults,
1992).
Assess the client's nutritional status. Refer for
a nutritional consult and/or institute dietary
supplements as necessary. Optimizing
nutritional intake, including calories, fatty acids,
protein, and vitamins, is needed to promote
wound healing (Russell, 2001). EB: The benefit
of nutritional evaluation and intensive
nutritional support in clients at risk for and with
pressure ulcers is not supported by rigorous
clinical trials. Despite this lack of evidence,
NPUAP (2006) endorses the application of
reasonable nutritional assessment and
treatment for clients at risk for and with
pressure ulcers.
Identify the client's phase of wound healing
(inflammation, proliferation, maturation) and
stage of injury. Accurate understanding of
tissue status combined with knowledge of
underlying diagnoses and product validity
provide a basis for determining appropriate
treatment objectives. No single wound dressing
is appropriate for all phases of wound healing
(Ovington, 1999).
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