Question

Module 08 Assignment – Nursing Interventions

Purpose of the Assignment

1. Plan evidence-based interventions to assist the client in meeting optimum outcomes.
2. The actions planned are designed to meet the health care needs of the client

Course Competencies

• Apply knowledge of integumentary disorders for safe, effective nursing care
• Explain components of multidimensional nursing care for clients with musculoskeletal disorders
• Select appropriate nursing interventions for clients experiencing alterations in mobility

Instructions

Develop a SMART client-centered outcome and individualized nursing interventions with rationale (using the template on page 2 of this document) for a client with the following nursing diagnosis on the care plan.

• Risk for impaired skin integrity related to mechanical factors and impaired physical mobility.

Answer 1

Clients with musculoskeletal disorders may require assistance with mobility, pain control, cast care, nutritional needs and emotional problems. While providing care to patients with musculoskeletal disorders, multidimensional approach is beneficial, that includes support from family members, physical therapist, occupational therapist, dietician and nurses. Nursing care is provided by assessing the condition of the patient, providing interventions and outcome.

The nursing interventions consists of :

1)Preventing disorders of Immobility : Prolonged bedrest is dangerous for clients with musculoskeletal disorders because of the increased risk for complications such as skin breakdown, contractures, constipation and thromboembolism.

2)Providing comfortable position and proper alignment : Maintaining proper body alignment is essential. Turn clients frequently to prevent skin breakdown. Pillows, sandbags and splints help to prevent foot drop and contractures. ROM exercises promote and maintain joint mobility and muscle strength. Encourage clients to move independently as much as possible.

3)Providing skin integrity :Maintaining skin integrity and protect against irritation. Reduce friction and shear forces through proper positioning. Minimize the use of soap. Use lotion for cleansing and for soothing dry skin. Use special beds, air mattress, foam pads to reduce pressure.

4)Providing adequate nutrition : for healing of wound encourage to take high protein diet. Increase the intake of fiber and fluids to maintain elimination.

NURSING CARE PLAN :

Nursing diagnosis :Risk for impaired skin integrity related to mechanical factors and impaired physical mobility.

Desired outcome: patients skin will remain intact as evidenced by no redness over bony prominences.

Nursing Interventions :

1.Assess the general condition of the patient (skin turgor, elasticity, moisture, temperature)

2. Assess the skin over bony prominences

3.Assess the wound, if present

4.Assess the patients ability to move

5.Assess the nutritional status of the patient.

RATIONALE :

1. Provides baseline data.

2.Higher risk for skin break down over bony prominences.

3.Help to measure the extent of woung and its healing process.

4.Immobility is the greatest risk for skin breakdown.

5 Patients with musculoskeletal disorders require diet rich in protein. Provide supplements for faster recovery.