Family needs & problem list.

Date Family name Family needs/problems Comment

Client : Problems
 Solved
randa Mohamed 1. altered in cardiovascular system related to
abdelaty hypertension As evidenced by:
- Tachycardia
- Decreased oxygen saturation
- Chest pain (angina)
- Difficulty breathing (dyspnea)
- Rapid breathing (tachypnea)
- Restlessness
- Fatigue
2. Altered in endocrine system related to diseases  Solved
process " diabetes mellitus" as evidenced by :
- Frequent urination (polyuria)
- Increased thirst (polydipsia)
- Increased feeling of hunger (polyphagia)
- Blurred vision
- Burning, tingling, or numbness in lower
extremities
- Fatigue
- Headaches
3. Ineffective Tissue Perfusion
Related to: Impaired oxygen transport
-Interruption in blood flow - Elevated blood  Not solved
glucose level
As evidenced by:
 Weak or absent peripheral pulses
 Numbness
 Pain
 Cool, clammy skin
 Difference in BP in opposite extremities
 Prolonged capillary refill
4. Acute Pain Related to: Blockage of coronary  Not solved
arteries Low or no oxygen-rich blood flowing to
the heart .As evidenced by:
- Verbal reports of chest pain, pressure, or
tightness
- Restlessness
- Labored breathing and dyspnea
 Needs
1. Knowledge deficit about complications  Client respond with
management and healthy nutrition for client me well
with hypertension as evidenced by client asks
many questions  Client respond with
me well
2. Knowledge deficit about complications of
wound to prevent infection as evidenced by
client asks many questions  Client respond with
me well
3. Knowledge deficit about diabetes or treatment
as evidenced by client asks many questions
 Client respond with
4. Knowledge deficit about psychological needs as me well
evidenced by client overload and sadness

Student name:
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 Family Pre-visit Plan

Visit Order:
Date Family Health Problems and Nursing Intervention
Member Needs
Sex/age "Nursing Diagnosis"
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Student signature

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 Family Nursing Care Plan

Visit Order:
Date Family Health Problems and Nursing Intervention
Member Needs
Sex/age "Nursing Diagnosis"
Ineffective Tissue Assessment:
Perfusion
Related to: 1. Conduct a thorough skin assessment.
 Interruption in A comprehensive head-to-toe skin examination should be carried out upon
blood flow admission, during unit transfers, and once every shift. This is done to monitor
and prevent skin breakdown during admission. Particular areas the nurse should
 Elevated blood take care to examine include any points at high risk of skin breakdown such as
glucose level the heels and coccyx.
 Sedentary lifestyle
 Insufficient 2. Utilize Braden Skin Assessment.
knowledge of An evidence-based approach for assessing the risk of pressure injuries is the
Braden Scale. The following are the six criteria on which the patient is assessed:
hyperglycemia
and its  Sensory perception
management  Moisture
 Poor control of  Activity
chronic health  Mobility
 Nutrition
conditions  Friction
As evidenced by:  Shear
 Decreased 3. Assess circulatory status.
peripheral pulses Examine the circulation, sensation, and turgor of the skin. The risk of tissue injury
is increased by poor skin turgor, diminished feelings (nerve damage), and poor
 Capillary refill
circulation (loss of blood flow indicated by reddish or purple skin discoloration of
time >2 seconds lower legs and palpable pulses).
 Cool, clammy
skin 4. Assess the activity level and mobility.
Observe the patient’s ability to walk and move in bed. Skin breakdown is typical
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in patients who cannot walk or have trouble shifting their weight in a chair or bed.
Patients who use restraints are also at high risk of skin breakdown.

5. Determine risk of skin breakdown related to moisture.

Note the patient’s increasing perspiration and incontinence. Evaluate the
patient’s body secretions, such as:

 Sweat/ perspiration
 Urine
 Stool
Patients who are incontinent are at a high risk of skin breakdown due to moisture
buildup.

6. Evaluate the patient’s ability to care for themselves.

Note the patient’s ability to manage incontinence and self-care. Patients who are
incontinent or unable to ask for help to go to the bathroom require constant
monitoring to maintain clean, dry skin.

7. Describe the wound.

Accurate recording of observed wounds and skin breakdown is necessary to
track the healing process and the efficacy of treatments. In addition to providing
thorough descriptions of drainage, the periwound region, odor, and any tunneling
or undermining, wounds must be precisely staged in terms of length, width, and
depth. It is advisable to take a picture for comparative purposes.

8. Assess the patient’s nutrition and hydration.

Monitor the patient’s diet and fluids. Adequate fluids improve oxygen and
nutrition delivery to the wound site. Consuming foods and supplements high in
protein is crucial for healing bodily tissues.

9. Assess the stoma and ostomy.

A wound care specialist assesses if a newly created stoma is healing properly.
They also check the appropriateness of the applied ostomy equipment.

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Nursing Interventions

Nursing interventions and care are essential to prevent and treat impaired skin
integrity. In the following section, you’ll learn more about possible nursing
interventions for a patient with impaired skin integrity.

1. Implement wound care protocols as prescribed.

Apply appropriate wound care protocols depending on the wound’s type, size,
and location. Wound care protocols depend on the wound care specialist’s
advice or the facility’s policies and procedures.

2. Position the patient comfortably.

Protect the bony prominences, relieving the bone from pressure. Patients who
are unable to ambulate should be repositioned at least every two hours or as per
the facility’s protocols. The nurse may be guided with a turn clock to cue
repositioning of the patient.

3. Ensure adequate skin perfusion.

Use cushions or other positioning devices as a support for the following bony
prominences:

 Elbows
 Knees
 Hips
 Heels
4. Determine the patient’s continence and skin moisture.
The nurse should maintain dry, clean skin for the patient. Sweat, stool, and urine
irritate the skin. Thus, keeping clothes, bed sheets, and perineal area dry is
essential.5. Alleviate the pressure.
Repositioning and pressure relief are facilitated by a low-air loss mattress that
cycles between inflating and deflating to simulate a patient shifting in bed. Make
use of air mattresses and the proper equipment. Offloading can be aided by:

 Wedge pillows
 Waffle boots
 Gel overlays on chairs and beds
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6. Promote proper nutrition and fluids.
Promote healthy nutrition and hydration. Collaborate with the dietitian to meet the
patient’s recommended diet and fluid intake.

7. Protect the skin from further injury.

Ensure protection of the skin, such as wearing socks or non-slip shoes. Patients
with compromised neurovascular status (such as diabetic patients) have to
protect their feet to prevent skin injuries because they have reduced sensation in
their lower legs and feet.

8. Coordinate with a wound/ostomy specialist.

A wound care/ostomy specialist can recommend, evaluate, and give instructions
regarding the appropriate wound care protocol.

9. Avoid irritation.
Pastes and powders minimize skin irritation. The stoma’s and any areas exposed
to moisture may become irritated. Thus, barrier pastes and powders may be
necessary to reduce irritation. For patients with an ostomy, removing the pouch
becomes simpler with adhesive removers that do not damage the skin.

10. Manage the ostomy pouch.

Teach patients how to empty and fit their ostomy pouches correctly. Sealing
around the stoma to stop leaks and irritation of the peristomal skin can be
achieved by carefully sizing the adhesive wafer and fitting the pouch system.
Empty the ostomy pouch when they are ⅓ to ½ full to keep pouches from tearing
away from the skin.

Student signature

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