A holistic approach to caring for patients with multiple sclerosis (MS)

Full Answer Section

• • The patient will participate in at least two assisted repositioning sessions per shift.
• Within 3 weeks:
  • The patient's family members will demonstrate proper techniques for assisting with repositioning and skin checks.
  • The patient will have no evidence of skin breakdown or pressure ulcers.
• Within 4 weeks:
  • The patient will consistently maintain skin integrity throughout the remainder of the clinical experience.
  • The patient and family will verbalize understanding of long term skin integrity maintenance.

Nursing Interventions (Specific and Achievable):

• Skin Assessment:
  • Perform thorough skin assessments at least twice daily, paying close attention to bony prominences and areas exposed to moisture.
  • Document all findings, including any redness, warmth, or skin breakdown.
• Repositioning:
  • Assist with repositioning the patient every 2 hours, using pillows or wedges to relieve pressure.
  • Ensure proper body alignment and avoid shearing forces.
  • Educate the patient and family on the importance of frequent repositioning.
• Incontinence Management:
  • Implement a scheduled toileting program, offering toileting every 2-3 hours.
  • Apply barrier cream to the perineal area after each episode of incontinence.
  • Change incontinence products frequently to minimize skin exposure to moisture.
  • Monitor and document the amount and frequency of incontinent episodes.
• Moisture Management:
  • Keep the skin clean and dry.
  • Use gentle cleansers and avoid harsh soaps.
  • Pat the skin dry rather than rubbing.
• Nutritional Support:
  • Encourage a high-protein diet to support skin healing and overall health.
  • Ensure adequate hydration.
  • Communicate with the dietician regarding the patients nutritional needs.
• Education:
  • Educate the patient and family about pressure ulcer prevention, including skin care techniques, repositioning, and incontinence management.
  • Provide written materials and demonstrations as needed.
• Collaboration:
  • Communicate with the interprofessional team, including physical therapy, occupational therapy, and the case manager, to ensure coordinated care.
  • Advocate for the patient's needs, such as the provision of pressure-relief mattresses or other assistive devices.
• Fall Prevention:
  • Ensure the call light is always within reach.
  • Assist with ambulation as needed.
  • Keep the environment free of clutter.

Evaluation:

• Regularly evaluate the effectiveness of the interventions by assessing the patient's skin integrity and monitoring for any signs of breakdown.
• Document all evaluations and adjust the care plan as needed.
• Obtain feedback from the patient and family regarding comfort and effectiveness of the care.

Student Nurse Considerations:

• As a student nurse, focus on providing direct care, such as skin assessments, repositioning, and incontinence management.
• Actively participate in interprofessional rounds and communicate with the healthcare team.
• Use this clinical experience to enhance your knowledge and skills in pressure ulcer prevention and skin care.
• Ensure all actions are done under the supervision of your clinical instructor.

By implementing this comprehensive plan, the student nurse can contribute significantly to the patient's skin integrity and overall well-being during the 4-week clinical experience.

Sample Answer

Absolutely. Based on the provided information, the priority concern is maintaining skin integrity and preventing pressure ulcers due to the patient's incontinence and mobility challenges.

Here's a nursing care plan focused on this priority, with specific, measurable, achievable, relevant, and time-bound (SMART) goals for a 4-week clinical experience:

Nursing Diagnosis: Risk for impaired skin integrity related to incontinence and impaired physical mobility as evidenced by history of incontinence and reported difficulty with mobility.

Goal: The patient will maintain intact skin integrity throughout the 4-week clinical experience, with no development of pressure ulcers.

Expected Outcomes (Measurable and Time-Bound):

• Within 1 week:
  • The patient will demonstrate understanding of proper skin care techniques, including the importance of regular repositioning and barrier cream application.
  • The patient's skin will remain free of redness or irritation in areas prone to pressure (sacrum, heels, hips).
• Within 2 weeks:
  • The patient will experience a reduction in incontinence episodes through consistent toileting schedules and appropriate incontinence product use.