Nursing Diagnosis: Skill Analysis Framework, Skill Performance - Case Study Example

INTRODUCTION In the 1950’s, the nursing process was introduced and has become the basis in providing effective nursing care. It requires the skills of assessment of the patient, problem identification by analyzing data, planning by setting goals, implementation by putting the plan into action and evaluation by assessing the effectiveness of the plan. Nursing diagnosis is an important part of the nursing process. It aids nurses in identifying patient problems and selecting nursing interventions to achieve outcomes desired. The North American Nursing Diagnosis Association (NANDA) has a list of nursing diagnosis to set a standard for nursing practice. The nursing process is used in doing this case study. My case study is Mr. David Wong, a 78 year old Chinese-Australian widower who has Type 2 Diabetes Mellitus which is controlled with medications and diet. He fell resulting to fracture of his right femur and subsequent hip replacement surgery. During his hospitalization, he developed a pressure sore on his left heel which improved upon his discharge. A month prior to his present admission, his wife died. Mr. Wong’s health declined. He was found in bed by his son, incontinent of urine and the pressure sore on his left heel was much worse. He was immediately brought to the Emergency Room where he was assessed as having a stage 3 pressure sore on his left heel. As a registered nurse, I need to make a nursing care plan using the nursing process. It starts with assessing the patient. Analyzing the data would help me identify Mr. Wong’s needs. These needs are expressed as nursing diagnosis. This nursing diagnosis requires nursing interventions which has desired outcomes to evaluate the care provided. ASSESSMENT AND PLANNING Assessment Mr. Wong complained that the affected area is painful to touch. Upon further assessment, there is disruption of skin surface, is erythematous and has moderate amount of purulent exudate. His initial vital signs were Tº - 37.7, BP – 130/90mmHg, HR – 88bpm, RR – 20 cycles/min, SaO2 – 96%. His laboratory tests also indicated he has elevated WBC count. Nursing Diagnosis Based on the data I have collected, Mr. Wong’s problems are impaired skin integrity, acute pain and risk for infection. Impaired Skin Integrity Impaired skin integrity is defined as altered epidermis or dermis. Stage 3 pressure ulcer is full-thickness skin loss involving necrosis of subcutaneous tissue. His physical inactivity, inadequate nutrition, advanced age and medical condition like diabetes mellitus contributed to the development of the pressure ulcer. To address this problem, the patient should display timely healing of skin wound without complications, maintain optimal nutrition, participate in treatment program and to verbalize feelings of increased self-esteem. To achieve these goals, the nursing priorities are to promote patient’s healing and promote wellness. Skin should be inspected daily. Wound should be observed regularly to monitor progress of healing. The affected area should be kept clean and dry, wound should be carefully dressed and circulation be stimulated to surrounding areas to assist body’s natural process of repair. Use wound dressing to protect wound and surrounding tissues. Remove wet linens promptly as moisture enhances skin breakdown. Involve patient in making decision regarding his treatment to enhance patient’s cooperation. Use padding devices to reduce pressure and enhance circulation to compromised tissue. Encourage early ambulation to promote circulation. Obtain specimen from wound for testing to determine appropriate treatment. Provide optimum nutrition to aid in healing and to maintain general good health. Assist the patient and family in understanding medical regimen to enhance their cooperation. Encourage patient to verbalize feelings. Lend psychological support to the patient using touch, facial expressions and tone of voice. Assist patient to learn stress reduction to help him deal with his situation. Refer patient to dietitian to enhance healing. Acute Pain Acute pain is an unpleasant sensory experience resulting from tissue damage. Mr. Wong felt pain as a result of his pressure ulcer. To resolve this problem, the patient should report pain is relieved, follow prescribed treatment, verbalize methods that provide relief and demonstrate use of relaxation skills. The nursing priorities are to evaluate patient’s response to pain, assist patient to explore methods for controlling pain and to promote wellness. Accept patient’s description of pain since pain is a subjective experience. Monitor vital signs which are usually altered in acute pain. Instruct patient to report pain immediately since prompt intervention is more successful in alleviating pain. Encourage verbalization of feelings about the pain. Provide quiet environment and comfort measures like back rub and use of heat or cold to provide nonpharmacological pain management. Encourage use of relaxation exercises. Administer analgesics as indicated to maintain acceptable level of pain. Encourage adequate rest periods to prevent fatigue. Risk for infection Mr. Wong is at risk for developing infection since has inadequate primary defense as evidenced by his broken skin. He is immunosuppressed, has diabetes mellitus and is malnourished. To address this problem, the patient should demonstrate techniques to promote a safe environment and achieve timely wound healing. The nursing priorities are to correct risk factors and to promote wellness. Stress proper handwashing techniques as a first-line defense against infection. Maintain sterile technique for invasive procedures. Clean wound site daily. Change dressings as needed. Review patient’s nutritional needs. Emphasize importance of taking antibiotics as directed since premature discontinuation of treatment may result in return of infection. Wound healing process Wound healing is regeneration of tissues. Two types of healing are primary and secondary intention healing. Primary intention healing occurs when tissue surfaces are approximated and there is minimal tissue loss. An example is a closed surgical wound. Secondary intention healing involves considerable tissue loss. A pressure ulcer is an example of this. In secondary intention healing, repair time is loner, scarring is greater and susceptibility to infection is greater. The three phases of wound healing are inflammatory, proliferative and maturation. Inflammatory phase starts after injury up to 3 to 6 days. Hemostasis or cessation of bleeding occurs in the area and blood clot formation results to a scab on surface of wound. Blood supply to the wound increases resulting to a reddened area. After 24 hours, macrophages engulf microorganisms through phagocytosis. The proliferative phase extends from day 3-4 to 21 days. Fibroblasts synthesize collagen to strengthen the wound. The maturation phase begins on day 21 and lasts 1-2 years. More collagen is synthesized resulting to wound remodeling. Age, nutritional status and lifestyle influence the speed of wound healing. In older adults like Mr. Wong, a lot of factors inhibit wound healing. Vascular changes associated with aging like atherosclerosis impair blood flow to the wound. Immunosuppression and nutritional deficiencies reduce antibody formation which is necessary for wound healing. Having diabetes mellitus increases risk of delayed healing due to impaired oxygen delivery to the tissues. Patients need a diet rich in protein, carbohydrates, lipids, vitamins A and C, minerals. This is supported by a study done by L. Frias Soriano et al published in Journal of Wound Care last September 2004. The study showed that patients with pressure ulcers who were given oral supplements rich in protein, arginine, vitamin C and zinc showed significant decrease in wound area and improvement in wound condition. Malnourished patients may require time to improve nutritional status. Obese clients are at increased risk of slower healing because adipose tissue has minimal blood supply. People who exercise regularly have good circulation and are more likely to heal quickly. NURSING SKILL Treating pressure ulcers is challenging for nurses because of factors like patient’s risk factors, types of ulcers and the many treatment options available. Infection is the main concern in treating pressure ulcers. Wound care requires the use of sterile technique, knowledge of wound healing, manual dexterity and visual acuity to perform skin assessment and wound treatment and problem solving skills to ensure patient safety. Equipments needed to perform wound care are gloves, alcohol, sterile gauze, cleansing agents, wound dressing, scissors, and paper tape. Do the dressing change at a time convenient for the patient. Explain to the client the procedure to enhance cooperation. Wash hands to prevent onset of infection. Provide for client privacy since undue exposure is physically and psychologically distressing. Wear clean gloves and thoroughly clean skin area around the wound and the wound using the prescribed solution. In a 2-year study done by C. Konya et al, published in Journal of Wound Care last April 2005 showed that cleansing the surrounding skin around the wound with cleanser promoted healing of the pressure ulcer. Apply the wound dressing. In Mr. Wong’s case, wet-to-dry dressing is used. An article about the study by U. Brunner et al, published in Journal of Wound Care last Sept. 2005, stated that wet-to-dry dressing is used to remove debris, exudates and pathogens from the wound to decrease itching and inflammation. Onset of infection is the primary concern in wound care. It is very important to adhere to the guidelines to prevent infection. In doing wound care, wash hands before and after caring for wound, wear gloves as appropriate and change dressings over wounds when they become wet. A good communication skill is also important. If procedures are explained well to the patient and his family, they will be cooperative. The nurse should do client teaching to promote wound healing and maintenance of healthy skin. REFLECTION I learned a lot by doing this case study. It has made me appreciate more my profession as a nurse and the nursing process used to help patients with their problems. I realized that being a nurse entails a lot of responsibilities and skills in caring for patients. In the course of my research, I have read a lot of journals relevant to wound care which broadened my knowledge. I am confident that with the knowledge I gained from doing this research, I will be a better nurse especially in dealing with patients with pressure ulcers in the future. Read More