ASSESSMENT Objective: Dx:CVDinfarct prob. c standbyO 2 @bedside c goodcapillaryrefill in 2-3secs.

c bodymalaise 2 weeksbedridden on CBRw/o BRP c limitedROM dry skin

NURSING DIAGNOSIS Risk forImpairedS kinIntegrity r/tprolonged bed restand alteredcircul ation .

RATIONALE Immobility, whichleads to pressure,shear, and friction, isthe factor most likelyto put an individual atrisk for altered skinintegrity. Advancedage; the normal lossof elasticity;inadequ ate nutrition;environ mentalmoisture, especiallyfrom incontinence;and vascularinsufficie ncypotentiate the effectsof pressure andhasten thedevelopment of skinbreakdown. Groups of persons with thehighest risk foraltered skin integrityare the spinal cordinjured, those whoare confined to bed orwheelchair forprolonged periods of time,

PLANNING After 1-2 hours of nursingintervention theclient and therelatives will beable to verbalizeunderstand ing of individual factorsthat contributeto possibility of skin integrityimpairment andtake steps tocorrect thesituation.As evidence by: understanding thesituation. patientsskinremaini ntact norednessover bonyprominences

INTERVENTION

RATIONALE

EVALUATION After 1-2 hours of nursinginterve ntion theclient and therelatives will beable to verbalizeunder standing of individual factorsthat contributeto possibility of skin integrityimpair ment andtake steps tocorrect thesituation.As evidence by: understanding thesituation. patientsskinre mainintact norednessove r bonyprominen ces

Place thept in acomfortableposit ion Take andrecord vitalsigns Determineage. Assessgeneralco ndition of skin

to prevent backachesor muscle aches. to note any significantchang es that may bebrought about by thedisease Elderly patients skin isnormally less elasticand has less moisture,making for higher riskof skin impairment. Healthy skin variesfrom individual toindividual, but shouldhave good turgor, feelwarm and dry to thetouch, be free of impairment, and havequick capillary refill (<6seconds).

those withedema, and thosewho have alteredsensation thattriggers the normalprotective weightshifting. Pressurerelief and pressurereductio n devices forthe prevention of skinbreakdown include awide range of surfaces, specialtybeds and mattresses,and other devices

ASSESSMENT Subjective:Objectiv e: Limitedrangeof motion(client cantfully extendhis right armand hold uphis rightshoulder) Limitedabilityand difficultyto performgross motorskills likeextending andlifting of theright arms SlowedMovement leftarm Dx: CVDinfarct prob. intubatedsince4/23/ 10 FIO2- @ 2-3LPM TV320, RR-20, PF-60

NURSING DIAGNOSIS Impairedphy sicalmobility r/tneuromusc ulardamagei nvolvement

RATIONALE CVD can becaused byan occlusion intheblood flow. Thiscanlead to O2 andthecause failure tonourish thetissues atthe capillarylevel andthat can causeneuromusc ulardamage w/ccan causeimpairedph ysicalmobility

PLANNING After 4 hrs of nursingintervention, therelatives will beable to participate intherapeutic regimenas evidence by: Verbalizationunderst anding of the situation andtherapy Able toparticipatein the interventionsrendere d by thenurse

INTERVENTION Independent: Determinedegree of Immobility Observemoveme ntwhen client isunaware Supportaffected partwith pillows Give restperiods toActivities Encourageadequ atefluids and rightdietas necessary totheclient

RATIONALE Independent: Toestablishcomp arativebaseline To noteanyincongru encewith thereportsof abilities Reducerisk of pressureulcers To helpreduce fatigueand O2demand energyproductio n

EVALUATION After 4 hrs of nursinginterve ntion, therelative are able toparticipate intherapeutic regimenas evidence by: Verbalizationu nderstanding of the situation andtherapy Able toparticipatein the interventionsre ndered by thenurse

A cerebrovascular accident (CVA) is a stroke, and involves the death of brain tissue due to clots or any other cause of blockage of blood flow to the brain. I've worked in Cardiopulmonary (heart and lungs) for 26 years and have never heard of a cardiovascular accident however, cardiovascular pertains to heart vessels, all of which supply blood to the body's tissues and organs, including the brain. Any vessel can become blocked and cause damage or death (depending on location and severity).