Question

Nursing Care Plan ) Case Study Linda Shaw is a 56-year-old female who was brought to the hospital by EMS on December 23, 2019. She presented to the emergency department with complaints of shortness of breath. She has had a productive cough for 3 days with a fever. She is admitted to the hospital with pneumonia and septicemia. She has a history of cellulitis, iron deficiency, high cholesterol and hypertension. She has an allergy to penicillin and vancomycin. She is taking ramipril 10mg daily, atorvastatin 20 mg daily and iron replacement daily. Since her arrival to hospital she has been on IV ceftriaxone 1gm q24 hours. She has been admitted for 2 days on the medicine unit that you are working on. Upon your assessment of the patient you notice she is short of breath during the interview. She can get no more than two words out before having to stop talking and rest. She is on wall oxygen at 2L via nasal prongs. You use your stethoscope to auscultate her chest and note decreased breath sounds to the LLL. You are aware that she has a left-sided pneumonia. You ask her to sit up in the bed and notice that she becomes increasingly short of breath with bed mobilization. Her respiratory rate is 24/min with evidence of accessory muscle use (abdominal breathing). You assess her oxygen saturation to be 92% on 2L of oxygen via nasal prongs. When asked if she has any pain the patient states “I have a heavy feeling in my chest”. You ask her what makes this pain worse, Linda states “The pain is worse when I am coughing”. You ask Linda when she first noticed the pain, “I first noticed the pain at 5am today”. Linda mentions that the pain in her chest seems to move into her throat. You ask Linda to describe the pain in her throat, “it is a scratchy pain”. Linda states that since changing her position on the bed she feels less pain. Linda states “before you asked me to move up in the bed my pain was 7/10 but since moving it is now 2/10 and mostly gone from my throat”. You assess Linda’s heart rate to be elevated (99 beats/min). You auscultate her apical pulse to match that finding. You note that her pulse is regular. You assess her blood pressure to be 111/80. You compare that to the blood pressure that the previous nurse had obtained overnight. Her pressure overnight was 118/79. You recognize that her blood pressure is lower than normal and ask her if she is dizzy or lightheaded, she tells you that she is not. Linda is alert and oriented and answering questions appropriately with no evidence of confusion. Upon assessment you note her pupils are equal and reactive bilaterally. Linda explains to you that she is feeling “unwell and tired”. She expresses frustration with her inability to sleep due to noise in the hallway at night. She tells you that she overheard the nurses talking all night long about baking Christmas cookies and it made her sad because she may not be home for Christmas. While Linda is talking to you about her inability to sleep, you notice that her oxygen saturation remains 92% despite her obvious shortness of breath when talking. Also, while she is talking to you, you take a look at her skin tone and note a normal skin colour and normal skin temperature. She does have dried blood at the site of her IV and the dressing is not intact. You assess her temperature to be elevated at 39 degrees Celsius. Linda also expresses frustration to you about being constipated, “I think I need some bran flakes. I haven’t had a bowel movement in 2 days”. Her abdomen does appear distended. You palpate all four of her abdominal quadrants and note they are soft and appear to be non-tender. You auscultate for bowel sounds and note that they are active in all quadrants. You ask Linda if she is passing gas, “you betcha” she replies. She tells you that before coming to the hospital she was 135lbs and that she believes she has lost weight. You ask her why she thinks this, “I haven’t eaten well since arriving to this hospital. I have no appetite and it seems to take a lot of effort to eat”. She seems to be moving her legs in bed frequently while you are interviewing her. You ask Linda, “Do you have pain in your legs?”. Linda explains that she does not have pain but rather wants to keep moving them so that she doesn’t “stiffen up”. Linda goes on to explain that she has had soreness and morning stiffness every morning for the last several years and her family doctor is investigating for arthritis. She denies requiring any mobility aids currently and denies any history of falls. You notice that Linda has a foley catheter insitu. There is 400cc of straw colour urine in the foley collection bag. You ask her why she has a catheter in. Linda states “the nurses put this catheter in while I was in the emergency department, they needed a urine specimen. Truthfully, I would like it out so that I can try to pee on my own”. Before terminating the interview, you hand Linda her cosmetic bag that she requested. She tears up and states, “I am not feeling much like putting make-up on. I fear that I will never get better. I seem to be wasting away in this bed. I am on my own with two kids in university so all that I can think about is who is going to work to pay for what they need. I need to get out of here!”. LAB VALUES AND DIAGNOSTIC TESTS FOR CASE STUDY #2 You can use the values below to add to the case study provided. If you have already developed the case study using your own lab values that is also acceptable. The idea is to explore the data and learn how to collect it in a comprehensive format along with identifying the priority nursing problem. WBC-16.2 Hgb-123 Plt-361 Na+-134 k-3.3 Cr-69 Glucose-6.2 CXR shows consolidation to left lower lung.

1. One Nursing diagnosis

2. One Short term goal

3. Four nursing interventions with cited rationale.

4. Evaluation: provide an explanation of what, when and how you would evaluate the nursing interventions

CLEAR HAND WRITTING ONLY PLEASE THANKS!1

Answer 1

Question 1.

Mrs. linda admitted to the hospital due to repiratory difficulties.ie shortness of breath.When the abdominal wall excursion during inspiration, expiration, or both do not maintain optimum ventilation for the individual, the nursing diagnosis Ineffective Breathing Pattern is one of the issues nurses need to focus on. It is considered the state in which the rate, depth, timing, and rhythm, or the pattern of breathing is altered. When the breathing pattern is ineffective, the body is most likely not getting enough oxygen to the cells. Respiratory failure may be correlated with variations in respiratory rate, abdominal, and thoracic pattern.

Goal and outcomes

• Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
• Patient’s respiratory rate remains within established limits.
• Patient’s ABG levels return to and remain within established limits.
• Patient indicates, either verbally or through behavior, feeling comfortable when breathing.
• Patient reports feeling rested each day.
• Patient performs diaphragmatic pursed-lip breathing.
• Patient demonstrates maximum lung expansion with adequate ventilation.
• When patient carries out ADLs, breathing pattern remains normal.

Nursing Assessment

Continuous assessment is necessary in order to know possible problems that may have lead to Ineffective Breathing Pattern as well as name any concerns that may occur during nursing care.

Assessment

• Assess and record respiratory rate and depth at least every 4 hours.

• Assess ABG levels, according to facility policy.	This monitors oxygenation and ventilation status.
  Analyzing Blood Gas
  1. Note the pH.	Determine if it is acidosis or alkalosis.
  2. Note the PaCO2.	Is it normal, increased, or decreased
  3. Note the HCO3.	Is it normal, increased, or decreased
  4. Note the base.	Excess or deficit
  5. Note the PaO2.

Observe for breathing patterns.

Rates and Depths of Respiration
Apnea	Temporary cessation of breathing, especially during sleep
Apneusis	Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release
Ataxic patterns	Complete irregularity of breathing with irregular pauses and increasing periods of apnea
Biot’s respiration	Groups of quick, shallow inspirations followed by regular or irregular periods of apnea (10 to 60 seconds).
Bradypnea	Respirations fall below 12 breaths per minute depending on the age of patient
Cheyne-Stokes respiration	Progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
Eupnea	Normal, good, unlabored ventilation, sometimes known as quiet breathing or resting, respiratory rate
Hyperventilation	Increased rate and depth of breathing
Kussmaul’s respirations	Deep respirations with fast, normal, or slow rate associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure
Tachypnea	Rapid, shallow breathing, with more than 24 breaths per minute

Auscultate breath sounds at least every 4 hours.

bnormal Breath Sounds
Bronchospasm	Constant breath sounds of both rhonchi and wheezing; normally treated with bronchodilator.
Expiratory grunt	Frequently occurs in combination with nasal flaring and intercostal or subcostal retractions, associated with increased work of breathing.
Rales	Clicking, rattling, or crackling sound heard during inspiration and expiration.
Rhonchi	Coarse crackle sound that is wetter than a rale, suctioning recommended.
Stridor	High-pitched, musical breathing sound caused by a blockage in the throat or voice box (larynx).
Wheeze	High-pitched, whistling sound when air moves through narrowed breathing tubes in the lungs. This is heard most commonly in asthmatics and CHF
Ask if they are “short of breath” and note any dyspnea.	Sometimes anxiety can cause dyspnea, so watch the patient for “air hunger” which is a sign that the cause of shortness of breath is physical.
Assess for use of accessory muscle.	Work of breathing increases greatly as lung compliance decreases.
Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).	Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is indicative of respiratory muscle fatigue and weakness.
Observe for retractions or flaring of nostrils.	These signs signify an increase in respiratory effort.
Assess the position that the patient assumes for breathing.	Orthopnea is associated with breathing difficulty.
Utilize pulse oximetry to check oxygen saturation and pulse rate.	Pulse oximetry is a helpful tool to detect alterations in oxygenation initially; but, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would require being obtained.
Inquire about precipitating and alleviating factors.	Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of breathing problems.
Assess ability to mobilize secretions.	The incapability to mobilize secretions may contribute to change in breathing pattern.
Observe presence of sputum for amount, color, consistency.	These may be indicative of a cause for the alteration in breathing pattern.
Send specimen for culture and sensitivity testing if sputum appears to be discolored.	This may signify infection.
Evaluate level of anxiety.	Hypoxia and sensation of “not being able to breathe” are frightening and may worsen hypoxia.
Note for changes in level of consciousness.	Restlessness, confusion, and/or irritability can be early indicators of insufficient oxygen to the brain.
Evaluate skin color, temperature, capillary refill; observe central versus peripheral cyanosis.	Lack of oxygen will cause blue/cyanosis coloring to the lips, tongue, and fingers. Cyanosis to the inside of the mouth is a medical emergency!
Assess for thoracic or upper abdominal pain.	Pain can result shallow breathing.
Keep away from high concentration of oxygen in patients with chronic obstructive pulmonary disease (COPD).	Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When administering oxygen, close monitoring is very important to avoid hazardous risings in the patient’s PaO2, which could lead to apnea.
Evaluate nutritional status (e.g., weight, albumin level, electrolyte level).	Malnutrition may result in premature development of respiratory failure because it reduces respiratory mass and strength.

Nursing Interventions

The following are the therapeutic nursing interventions for ineffective breathing pattern:

Interventions	Rationales
Place patient with proper body alignment for maximum breathing pattern.	A sitting position permits maximum lung excursion and chest expansion.
Encourage sustained deep breaths by: Using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation Utilizing incentive spirometer Requiring the patient to yawn	These techniques promotes deep inspiration, which increases oxygenation and prevents atelectasis. Controlled breathing methods may also aid slow respirations in patients who are tachypneic. Prolonged expiration prevents air trapping.
Encourage diaphragmatic breathing for patients with chronic disease.	This method relaxes muscles and increases the patient’s oxygen level.
Evaluate the appropriateness of inspiratory muscle training.	This training improves conscious control of respiratory muscles and inspiratory muscle strength.
Provide respiratory medications and oxygen, per doctor’s orders.	Beta-adrenergic agonist medications relax airway smooth muscles and cause bronchodilation to open air passages.
Avoid high concentration of oxygen in patients with COPD.	Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When administering oxygen, close monitoring is very important to avoid uncertain risings in the patient’s PaO2, which could lead to apnea.
Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing.	This facilitates adequate clearance of secretions.
Suction secretions, as necessary.	This is to clear blockage in airway.
Stay with the patient during acute episodes of respiratory distress.	This will reduce the patient’s anxiety, thereby reducing oxygen demand.
Ambulate patient as tolerated with doctor’s order three times daily.	Ambulation can further break up and move secretions that block the airways.
Encourage frequent rest periods and teach patient to pace activity.	Extra activity can worsen shortness of breath. Ensure the patient rests between strenuous activities.
Consult dietitian for dietary modifications.	COPD may cause malnutrition which can affect breathing pattern. Good nutrition can strengthen the functionality of respiratory muscles.
Encourage small frequent meals.	This prevents crowding of the diaphragm.
Help patient with ADLs, as necessary.	This conserves energy and avoids overexertion and fatigue.
Avail a fan in the room.	Moving air can decrease feelings of air hunger.
Encourage social interactions with others that have medical diagnoses of ineffective breathing pattern.	Talking to others with similar conditions can help to ease anxiety and increase coping skills.
Educate patient or significant other proper breathing, coughing, and splinting methods.	These allow sufficient mobilization of secretions.
Educate patient about medications: indications, dosage, frequency, and possible side effects. Incorporate review of metered-dose inhaler and nebulizer treatments, as needed.	This information promotes safe and effective medication administration.
Teach patient about: pursed-lip breathing abdominal breathing performing relaxation techniques performing relaxation techniques taking prescribed medications (ensuring accuracy of dose and frequency and monitoring adverse effects) scheduling activities to avoid fatigue and provide for rest periods

Question 2.

Setting of goal is very important and also have to achieve it.

Goal and outcomes

• Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
• Patient’s respiratory rate remains within established limits.
• Patient’s ABG levels return to and remain within established limits.
• Patient indicates, either verbally or through behavior, feeling comfortable when breathing.
• Patient reports feeling rested each day.
• Patient performs diaphragmatic pursed-lip breathing.
• Patient demonstrates maximum lung expansion with adequate ventilation.

Question 3.

1) Ineffective airway clearance

Nursing Assessment for Ineffective Airway Clearance

Continuous assessment is necessary in order to know possible problems that may have lead to Ineffective Airway Clearance as well as name any concerns that may occur during nursing care.

Assessment	Rationales
Assess airway for patency.	Maintaining patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest.
Auscultate lungs for presence of normal or adventitious breath sounds, as in the following:	Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate ineffective airway clearance.
Decreased or absent breath sounds	These may indicate presence of a mucous plug or other major obstruction.
Wheezing	This may indicate partial airway obstruction or resistance.
Coarse crackles	This may indicate presence of secretions along larger airways.
Abnormal Breath Sounds:
Bronchospasm	Constant breath sounds of both rhonchi and wheezing; normally treated with bronchodilator.
Expiratory grunt	Frequently occurs in combination with nasal flaring and intercostal or subcostal retractions, associated with increased work of breathing.
Rales	Clicking, rattling, or crackling sound heard during inspiration and expiration.
Rhonchi	Continuous low-pitched, rattling lung sounds that often resemble snoring.
Stridor	High-pitched, musical breathing sound caused by a blockage in the throat or voice box (larynx).
Wheeze	High-pitched, whistling sound when air moves through narrowed breathing tubes in the lungs. This is heard most commonly in asthmatics and CHF
Assess respirations. Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing.	A change in the usual respiration may mean respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction.
Rates and Depths of Respiration:
Apnea	Temporary cessation of breathing, especially during sleep
Apneusis	Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release
Ataxic patterns	Complete irregularity of breathing with irregular pauses and increasing periods of apnea
Biot’s respiration	Groups of quick, shallow inspirations followed by regular or irregular periods of apnea (10 to 60 seconds).
Bradypnea	Respirations fall below 12 breaths per minute depending on the age of patient
Cheyne-Stokes respiration	Progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
Eupnea	Normal, good, unlabored ventilation, sometimes known as quiet breathing or resting, respiratory rate
Hyperventilation	Increased rate and depth of breathing
Kussmaul’s respirations	Deep respirations with fast, normal, or slow rate associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure
Tachypnea	Rapid, shallow breathing, with more than 24 breaths per minute
Note for changes in mental status.	Increasing lethargy, confusion, restlessness, and/or irritability can be initial signs of cerebral hypoxia. Lethargy and somnolence are late signs.
Note for changes in HR, BP, and temperature.	Increased work of breathing can lead to tachycardia and hypertension. Retained secretions or atelectasis may be a sign of an existing infection or inflammatory process manifested by a fever or increased temperature.
Note cough for efficacy and productivity.	Coughing is a mechanism for clearing secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough.
Note presence of sputum; evaluate its quality, color, amount, odor, and consistency.	Unusual appearance of secretions may be a result of infection, bronchitis, chronic smoking, or other condition. A discolored sputum is a sign of infection; an odor may be present. Dehydration may be present if patient has labored breathing with thick, tenacious secretions that increase airway resistance.
Submit a sputum specimen for culture and sensitivity testing, as appropriate.	Labored breathing may be a sign of respiratory infection that needs an appropriate treatment of antibiotics.
Use pulse oximetry to monitor oxygen saturation; assess arterial blood gases (ABGs)	Pulse oximetry is used to detect changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. Alteration in ABGS may result in increased pulmonary secretions and respiratory fatigue.
Normal Blood Gas Values:
pH	7.35 – 7.45
PaCO2	35 – 45
PaO2	Adults: 80 – 100 Infants: 60 – 80
HCO3	20 – 24
Assess hydration status: skin turgor, mucous membranes, tongue.	Airway clearance is impaired with poor hydration and subsequent secretion thickening.
Assess for abdominal or thoracic pain.	Pain can result in shallow breathing and an ineffective cough.
Check for peak airway pressures and airway resistance, if patient is on mechanical ventilation.	Increases in these parameters signal collection of secretions or fluid and likely for ineffective ventilation.

Nursing Interventions	Rationales
Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession).	The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing.
Educate the patient in the following: Optimal positioning (sitting position) Use of pillow or hand splints when coughing Use of abdominal muscles for more forceful cough Use of quad and huff techniques Use of incentive spirometry Importance of ambulation and frequent position changes	The proper sitting position and splinting of the abdomen promote effective coughing by increasing abdominal pressure and upward diaphragmatic movement. Controlled coughing methods help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. Ambulation promotes lung expansion, mobilizes secretions, and lessens atelectasis.
Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed.	Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange.
Perform nasotracheal suctioning as necessary, especially if cough is ineffective.	Suctioning is needed when patients are unable to cough out secretions properly due to weakness, thick mucus plugs, or excessive or tenacious mucus production.
Explain procedure to patient	This procedure can also stimulate a cough. Frequency of suctioning should be based on patient’s present condition, not on preset routine, such as every 2 hours. Over suctioning can cause hypoxia and injury to bronchial and lung tissue.
Use well-lubricated soft catheters	Using well-lubricated catheters reduces irritation and prevents trauma to mucous membranes.
Use curved-tip catheters and head positioning (if not contraindicated).	These facilitates secretion removal; from a specific side of the lung (left or right).
Instruct the patient to take several deep breaths before and after nasotracheal suctioning procedure and use supplemental oxygen, as appropriate.	Hyperoxygenation before, during, and after suctioning prevents hypoxia.
Stop suctioning and provide supplemental oxygen if the patient experiences bradycardia, an increase in ventricular ectopy, and/or significant desaturation.	Oxygen therapy is recommended to improve oxygen saturation and reduce possible complications.
Use universal precautions: gloves, goggles, and mask, as appropriate.	As protection against the blood-related modes of transmission, health care workers should use universal precautions when coming in contact with the blood of all patients, or bodily fluids containing blood.
Maintain humidified oxygen as prescribed.	Increasing humidity of inspired air will reduce thickness of secretions and aid their removal.
Encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function.	Fluids help minimize mucosal drying and maximize ciliary action to move secretions.
Give medications as prescribed, such as antibiotics, mucolytic agents, bronchodilators, expectorants, noting effectiveness and side effects.	A variety of medications are prepared to manage specific problems. Most promote clearance of airway secretions and may reduce airway resistance.
Coordinate with a respiratory therapist for chest physiotherapy and nebulizer management as indicated.

2) Impaired Skin Integrity

Nursing Diagnosis

• Impaired Skin Integrity

Related Factors

• Contact with irritants or allergens

Defining Characteristics

Desired Outcomes

• Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin

Nursing Interventions	Rationale
Assess skin, noting color, moisture, texture, temperature; note erythema, edema, tenderness.	Specific types of dermatitis may have characteristic patterns of skin changes and lesions.
Assess the skin systematically. Look for areas of irritant and allergic contact.	Flexural areas (elbows, neck, posterior knees) are common areas affected in atopic dermatitis.
Assess skin for lesions. Note presence of excoriations, erosions, fissures, or thickening.	Open skin lesions increase the patient’s risk for infection. Thickening occurs in response to chronic scratching (lichenification).
Identify aggravating factors. Inquire about recent changes in use of products such as soaps, laundry products, cosmetics, wool or synthetic fibers, cleaning solvents, and so forth.	Patients may develop dermatitis in response to changes in their environment. Extremes of temperature, emotional stress, and fatigue may contribute to dermatitis.
Identify signs of itching and scratching.	The patient who scratches the skin to relieve intense itching may cause open skin lesions with an increased risk for infection. Characteristic patterns associated with scratching include reddened papules that run together and become confluent, widespread erythema, and scaling or lichenification
Identify any scarring that may have occurred.	Long-term scarring may result in body image disturbances.
Encourage the patient to adopt skin care routines to decrease skin irritation:	One of the first steps in the management of dermatitis is promoting healthy skin and healing of skin lesions.
Bathe or shower using lukewarm water and mild soap or nonsoap cleansers.	Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
After bathing, allow the skin to air dry or gently pat the skin dry. Avoid rubbing or brisk drying.	Rubbing the skin with a towel can irritate the skin and exacerbate the itch-scratch cycle.
Apply topical lubricants immediately after bathing.	Lubrication with fragrance-free creams or ointments serves as a barrier to prevent further drying of the skin through evaporation. Moisturizing is the cornerstone of treatment. Over-the-counter moisturizing lotions include Eucerin, Lubriderm, and Nivea. Lotions are lighter and less emollient than creams. If more moisturizing is required than a lotion can provide, a cream is recommended. These include Keri cream, Cetaphil cream, Eucerin cream, and Neutrogena Norwegian formula. Ointments are the most emollient. Vaseline Pyre Petroleum Jelly or Aquaphor Natural Healing Ointment may be beneficial.
Apply topical steroid creams or ointments.	These drugs reduce inflammation and promote healing of the skin. The patient may begin using over-the-counter hydrocortisone preparations. If these are not effective, the physician may include prescription corticosteroids for topical use. Usual application is twice daily, thinly and sparingly. Do not use with an occlusive dressing, because this potentiates the action and systemic absorption of the steroid. Usual duration of use of topical steroids is up to 14 days in adults.
Apply topical immunomodulators (TIMs): Tacrolimus (Protopic) Pimecrolimus (Elidel)	Tacrolimus (Protopic) has recently been approved for the treatment of atopic dermatitis. TIMs alter the reactivity of cell-surface immunological responsiveness to relieve redness and itching. In 2005, the Food and Drug Administration advised a potential cancer risk with long-term use of pimecrolimus and tacrolimus based on animal studies.
Prepare the patient for phototherapy or photochemotherapy.	This treatment modality uses ultraviolet A or B light waves to promote healing of the skin. The addition of psoralen, which increases the skin’s sensitivity to light, may benefit patients who do not respond to phototherapy alone.
Encourage the patient to avoid aggravating factors.	Some change in lifestyle may be indicated to reduce triggers.

3)

Disturbed Body Image

Nursing Diagnosis

• Disturbed Body Image

Related Factors

• Visible skin lesions

Defining Characteristics

• Verbalizes feelings about change in body appearance
• Verbalizes negative feelings about skin condition
• Fear of rejection or reactions of others

Desired Outcome

• Patient verbalizes feeling about lesions and continues daily activities and social interactions.

Nursing Interventions	Rationale
Assess the patient’s perception of changed appearance.	The nurse needs to understand the patient’s attitude about visible changes in the appearance of the skin that occur with dermatitis.
Assess the patient’s behavior related to appearance.	Patients with body image issues may try to hide or camouflage their lesions. Their socialization may decrease based on anxiety or fear about the reactions of others.
Assist the patient in articulating responses to questions from others regarding lesions and contagion.	Patients may need guidance in determining what to say to people who comment about the appearance of their skin. Dermatitis is not a contagious skin condition.
Allow patients to verbalize feelings regarding their skin condition.	Through talking, the patient can be guided to separate physical appearance from feelings of personal worth.
Assist patients in identifying ways to enhance their appearance.	Clothing, cosmetics, and accessories may direct attention away from the skin lesions. The patient may need help in selecting methods that do not aggravate the skin lesions.

4.

Risk for Infection

Nursing Diagnosis

• Risk for Infection

Risk Factors

• Impaired skin integrity
• Severe inflammation
• Excoriation

Desired Outcome

• Patient remains free of secondary infection.

Nursing Interventions	Rationale
Assess skin for severity of skin integrity compromise.	The skin is the body’s first line of defense against infection. Disruption of the integrity of skin increases the patient’s risk of developing an infection or of scarring.
Assess for signs of infection.	Patients with dermatitis are at highest risk for developing skin infections caused by staphylococcus aureus. Purulent drainage from skin lesions indicates infection. With severe infections, the patient may have an elevated temperature.
Apply topical antibiotics.	Topical antibiotics may be used to treat infections that occur with dermatitis.
Administer oral antibiotics.	Oral antibiotics may be more effective in treating infections on the skin.
Encourage the patient to use appropriate hygiene methods.	Keeping the skin clean, dry, and well lubricated reduces skin trauma and risk of infection.

question 4

Introduction

• Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the nursing process, the client’s condition or well-being improves. The nurse applies all that is known about a client and the client’s condition, as well as experience with previous clients, to evaluate whether nursing care was effective. The nurse conducts evaluation measures to determine if expected outcomes are met, not the nursing interventions.
• The expected outcomes are the standards against which the nurse judges if goals have been met and thus if care is successful.Providing health care in a timely, competent, and cost-effective manner is complex and challenging. The evaluation process will determine the effectiveness of care, make necessary modifications, and to continuously ensure favorable client outcomes.

Definition

• Is assessment the client’s response to nursing interventions and then comparing that response to predetermined standards or outcome criteria.

Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals; in this phase nurse compare the client behavioral responses with predetermined client goals and outcome criteria. –CRAVEN

IDENTIFYING CRITERIA AND STANDARDS

Nurses evaluate the nursing care by knowing what to look for.A clients goal and expected outcome give objective criteria needed a clients response to care.

COLLECTING EVALUATING DATA

• Evaluating client response
• Evaluating assessment and other reponses

INTERPRETING AND SUMMARISING FINDINGS

• Examine Goal statement to identify desired client bahaviour
• Assess behaviour response

DOCUMENTING FINDINGS

Documentation and reporting are major part of evaluation.

CARE PLAN REVISION

Evaluate expected outcome and determine if the goals of care havebeen met.Then decide the need to adjust the plan of care.