Question

Concept Map PATIENT CARE DOCUMENTATION LEVEL 2 CLINICAL COURSE PAGE 6 OF Signs and Symptoms Interventions for Nursing Diagnosis Lab Values Related to Nursing Diagnosis Nursing Diagnosis Rationales for Interventions Risk for potential Skin breakdown due to incontinence. Medication(s) r/t Diagnosis Patient Outcome(s) Medication Side Effects

Answer 1

Risk for skin breakdown related to urinary incontinance

Signs and symptoms(Dermatitis)

• Itching
• Reddness
• Inflammation
• Pressure Ulcer due to incontinanance
• Blisters

Intervention and rationale

• Assess the signs and symptoms of skin breakdown to get baseline data.
• Change position every 2hour to reduce pressure which causes ulcer
• clean ,dry and moisturize the area especially bony prominance. Smooth and supple skin resistant injury
• Wrap blisters with gauze to prevent entry of pathogens.
• Catheterization to prevent incontinance.
• Provide adequate nutrition which maintain skin intact.

Patient out come

• Patient maintain normal skin integrity.
• Patient gets free from impaired skin integrity

Medication

• Diuretics such as furesemide, aldactone etc
• Calcium channel blokers(diltiazem)
• ACE inhibitors(captopril,enalapril)
• Antiparkinsonism drugs
• Alpha antagonist

Lab value

• Blood sugar (hyperglycemia causes impaired skin integrity)
• Urine protein (protenuria causes skin break down)
• Serum protein