Question

1. Impaired skin integrity

-what are the assessment, goals/plan, nursing intervention, patient education, and evaluation (how did the goals met?)

2. Bowel Incontinence

--what are the assessment, goals/plan, nursing intervention, patient education, and evaluation (how did the goals met?)

3. Risk for Constipation

--what are the assessment, goals/plan, nursing intervention, patient education, and evaluation (how did the goals met?)

4. Fluid Volume Deficit

-what are the assessment, goals/plan, nursing intervention, patient education, and evaluation (how did the goals met?)

5. Risk for Falls

-what are the assessment, goals/plan, nursing intervention, patient education, and evaluation (how did the goals met?)

Thanks

Answer 1

1. Impaired skin integrity

assessment

• Assess site of impaired tissue integrity and its condition.- Redness, swelling, pain, burning, and itching are indication of inflammation and the body’s immune system response to localized tissue trauma or impaired tissue integrity.
• Assess characteristics of wound, including color, size (length, width, depth), drainage, and odor.-These findings will give information on extent of the impaired tissue integrity or injury. Pale tissue color is a sign of decreased oxygenation. Odor may be a result of presence of infection on the site; it may also be coming from a necrotic tissue. Serous exudate from a wound is a normal part of inflammation and must be differentiated from pus or purulent discharge, which is present in infection.
• Assess changes in body temperature, specifically increased in body temperature.-Fever is a systemic manifestation of inflammation and may indicate the presence of infection.
• Assess patient’s nutritional status; refer for a nutritional consultation and/or institute dietary supplements.-Inadequate nutritional intake places the patient at risk for skin breakdown and compromises healing further causing impaired tissue integrity.
• Classify pressure ulcers -Wound assessment is more reliable when classified in such manner according to the National Pressure Ulcer Advisory Panel.
• Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels.- Systematic inspection can identify impending problems early.

Goals and Outcomes

The following are the common goals and expected outcomes for Impaired Tissue Integrity nursing diagnosis and care planning. Use them in writing your short term or long term goals for your impaired tissue integrity care plan:

• Patient reports any altered sensation or pain at site of tissue impairment.
• Patient demonstrates understanding of plan to heal tissue and prevent injury.
• Patient describes measures to protect and heal the tissue, including wound care.
• Patient’s wound decreases in size and has increased granulation tissue.

Interventions

• Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection.
• Monitor status of skin around wound. Monitor patient’s skin care practices, noting the type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing
• Provide tissue care as needed. -ach type of wound is best treated based on its etiology. Skin wounds may be covered with wet or dry dressings, topical creams or lubricants, hydrocolloid dressings (e.g., DuoDerm) or vapor-permeable membrane dressings such as Tegaderm. An eye patch or hard, plastic shield for corneal injury. The dressing replaces the protective function of the injured tissue during the healing process.
• Keep a sterile dressing technique during wound care.
• Administer antibiotics as ordered.
• Do not position the patient on site of impaired tissue integrity. If ordered, turn and position patient at least every 2 hours, and carefully transfer patient
• provide adequate back care,ans massage

client education

• Educate patient about proper nutrition, hydration, and methods to maintain tissue integrity.
• Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing.
• Instruct patient, significant others, and family in the proper care of the wound including hand washing, wound cleansing, dressing changes, and application of topical medications)
• Encourage the use of pillows, foam wedges, and pressure-reducing devices.
• Educate the patient the need to notify the physician or nurse.

2.Bowel Incontinence

impaired bowel elimnation,diarrhea related to Inflammation, irritation, or malabsorption of the bowel

ASSESSMENT

• Assess general condition of the patient
• assess etiology. Chronic diarrhea (caused by irritable bowel syndrome, infectious diseases affecting colon such as IBD).
• assess for signs and symmptoms of dehydration such as skin turgor.tachycardia,lethargy

Desired Outcomes

• Report reduction in frequency of stools, return to more normal stool consistency.
• Identify/avoid contributing factors.

Interventions

• Observe and record stool frequency, characteristics, amount, and precipitating factors.
• Observe for presence of associated factors, such as fever, chills, abdominal pain,cramping, bloody stools, emotional upset, physical exertion and so forth.
• Promote bedrest, provide bedside commode.
• Remove stool promptly. Provide room deodorizers.
• Identify and restrict foods and fluids that precipitate diarrhea (vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products)
• Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids
• Provide opportunity to vent frustrations related to disease process.

client education

educate the client regarding good hygienic practices

Educate about strict maintanance of fluid status

advicw to eat proper caloric foods.

3.risk for constipation

risk for Constipation related to pain on defecation secondary to hemorrhoids

nursing outcome/goal

The patient will have a bowel movement before discharge.-The patient will report decreased pain in rectum from hemorrhoids.

-The patient will verbalize 3 techniques on how to keep bowel movements regular.

The patient will verbalize how to take prescribed medication regime to prevent constipation

Nursing interventions

-The nurse will provide the patient with a sitz bath and hemorrhoid cream as prescribed to help with hemorrhoid pain

.- encourage to take plenty of fluids

-aviod straining during bowel movement

-avoid prolongeg sitting

-provide high fiber diet,and include plenty of fruits and vegetables

he nurse administer per MD orders Miralax and Colace as prescribed to help assist patient with bowel movement.-The nurse assess and document when patient has had a bowel movement daily.

client education

-The nurse will educate the patient on 3 techniques on how to keep bowl movements regular by discharge.

-The nurse will educate the patient how to take prescribed medications to prevent constipation by discharge.

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