SuggestedNursing Outcomes Tissue Integrity: Skin and Mucous Membranes Wound Healing: Primary Intention Wound Healing: Secondary

Intention Client Outcomes Regains integrity of skin surface Reports any altered sensation or pain at site of skin impairment Demonstrates understanding of plan to heal skin and prevent reinjury Describes measures to protect and heal the skin and to care for any skin lesion Suggested Nursing Interventions Incision Site Care Pressure Ulcer Care Skin Care: Topical Treatments Skin Surveillance Wound Care Nursing Interventions and Rationales Nursing Interventions Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently . For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors. Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours Evaluate for use of specialty mattresses, beds

Rationales Prior assessment of wound etiology is critical for proper identification of nursing interventions. Systematic inspection can identify impending problems early.

A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear. To reduce shear and friction, and use lift devices, pillows, foam wedges, and pressurereducing devices in the bed.

Select a topical treatment that will maintain a moist woundhealing environment and that is balanced with the need to absorb exudates Avoid massaging around the site of skin impairment and over bony prominences. Assess client's nutritional status Expected Outcomes

Massage may lead to deep-tissue trauma Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing

Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.

Ongoing Assessment

Assess pain characteristics:

Quality (e.g., sharp, burning, shooting) Severity (scale of 1 to 10, with 10 being the most severe) Other methods such as a visual analog scale or descriptive scales can be

used to identify extent of pain. Location (anatomical description) Onset (gradual or sudden) Duration (how long; intermittent or continuous) Precipitating or relieving factors

Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness,

and ability to focus. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.

Assess for probable cause of pain. Different etiological factors respond better to different therapies. Assess patients knowledge of or preference for the array of pain-relief strategies available. Some patients may be unaware of the

effectiveness of nonpharmacological methods and may be willing to try them, either with or instead of traditional analgesic medications. Often a combination of therapies (e.g., mild analgesics with distraction or heat) may prove most effective.

Evaluate patients response to pain and medications or therapeutics aimed at abolishing or relieving pain. It is important to help patients

express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Discrepancies between behavior or appearance and what patient says about pain relief (or lack of it) may be more a reflection of other methods patient is using to cope with than pain relief itself.

Assess to what degree cultural, environmental, intrapersonal, and intrapsychic factors may contribute to pain or pain relief. These variables

may modify the patients expression of his or her experience. For example, some cultures openly express feelings, while others restrain such expression. However, health care providers should not stereotype any patient response but rather evaluate the unique response of each patient.

Evaluate what the pain means to the individual. The meaning of the pain will directly influence the patients response. Some patients,

especially the dying, may feel that the act of suffering meets a spiritual need. Assess patients expectations for pain relief. Some patients may be content to have pain decreased; others will expect complete elimination of

pain. This affects their perceptions of the effectiveness of the treatment modality and their willingness to participate in additional treatments. Assess patients willingness or ability to explore a range of techniques aimed at controlling pain. Some patients will feel uncomfortable

exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain. Assess appropriateness of patient as a patient-controlled analgesia (PCA) candidate: no history of substance abuse; no allergy to narcotic

analgesics; clear sensorium; cooperative and motivated about use; no history of renal, hepatic, or respiratory disease; manual dexterity; and no history of major psychiatric disorder. PCA is the intravenous (IV) infusion of a narcotic (usually morphine or Demerol) through an infusion pump that is controlled by the patient. This allows the patient to manage pain relief within prescribed limits. In the hospice or home setting, a nurse or caregiver may be needed to assist the patient in managing the infusion.

Monitor for changes in general condition that may herald need for change in pain relief method. For example, a PCA patient becomes

confused and cannot manage PCA, or a successful modality ceases to provide adequate pain relief, as in relaxation breathing. If patient is on PCA, assess the following:

Pain relief The basal or lock-out dose may need to be increased to cover the patients pain. Intactness of IV line If the IV is not patent, patient will not receive pain medication. Amount of pain medication patient is requesting If demands for medication are quite frequent, patients dosage may need to be

increased. If demands are very low, patient may require further instruction to properly use PCA. Possible PCA complications such as excessive sedation, respiratory distress, urinary retention, nausea/vomiting, constipation, and

IV site pain, redness, or swelling Patients may also experience mild allergic response to the analgesic agent, marked by generalized itching or nausea and vomiting.

If patient is receiving epidural analgesia, assess the following:

Pain relief Intermittent epidurals require redosing at intervals. Variations in anatomy may result in a patch effect. Numbness, tingling in extremities, a metallic taste in the mouth These symptoms may be indicators of an allergic response to the

anesthesia agent, or of improper catheter placement. Possible epidural analgesia complications such as excessive sedation, respiratory distress, urinary retention, or catheter migration

Respiratory depression and intravascular infusion of anesthesia (resulting from catheter migration) can be potentially life-threatening. Therapeutic Interventions

Anticipate need for pain relief. One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of

analgesic required. Respond immediately to complaint of pain. In the midst of painful experiences a patients perception of time may become distorted. Prompt

responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patients welfare and comfort fosters the development of a trusting relationship.

Eliminate additional stressors or sources of discomfort whenever possible. Patients may experience an exaggeration in pain or a decreased

ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them. Provide rest periods to facilitate comfort, sleep, and relaxation. The patients experiences of pain may become exaggerated as the result of

fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion. A quiet environment, a darkened room, and a disconnected phone are all measures geared toward facilitating rest.

Determine the appropriate pain relief method. Pharmacological methods include the following: Nonsteroidal antiinflammatory drugs (NSAIDs) that may be administered orally or parenterally

(to date, ketorolac is the only available parenteral NSAID). Use of opiates that may be administered orally, intramuscularly, subcutaneously, intravenously, systemically by patient-controlled analgesia

(PCA) systems, or epidurally (either by bolus or continuous infusion). Narcotics are indicated for severe pain, especially in the hospice or home setting.

Local anesthetic agents. Nonpharmacological methods include the following: Cognitive-behavioral strategies as follows:

Imagery The use of a mental picture or an imagined event involves use of the five senses to distract oneself from painful stimuli. Distraction techniques Heighten ones concentration upon nonpainful stimuli to decrease ones awareness and experience of pain.

Some methods are breathing modifications and nerve stimulation. Relaxation exercises Techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of

these techniques is to reduce tension, subsequently reducing pain. Biofeedback, breathing exercises, music therapy

2. Cutaneous stimulation as follows: Massage of affected area when appropriate Massage decreases muscle tension and can promote comfort. Transcutaneous electrical nerve stimulation (TENS) units Hot or cold compress Hot, moist compresses have a penetrating effect. The warmth rushes blood to the affected area to promote

healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort. Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects. Pain medications are

absorbed and metabolized differently by patients, so their effectiveness must be evaluated from patient to patient. Analgesics may cause side effects that range from mild to life-threatening.

Notify physician if interventions are unsuccessful or if current complaint is a significant change from patients past experience of pain. Patients

who request pain medications at more frequent intervals than prescribed may actually require higher doses or more potent analgesics. Whenever possible, reassure patient that pain is time-limited and that there is more than one approach to easing pain. When pain is perceived

as everlasting and unresolvable, patient may give up trying to cope with or experience a sense of hopelessness and loss of control. If patient is on PCA: Dedicate use of IV line for PCA only; consult pharmacist before mixing drug with narcotic being infused. IV

incompatibilities are possible. If patient is receiving epidural analgesia: Label all tubing (e.g., epidural catheter, IV tubing to epidural catheter) clearly to prevent inadvertent

administration of inappropriate fluids or drugs into epidural space.

For patients with PCA or epidural analgesia: Keep Narcan or other narcotic-reversing agent readily available. In the event of respiratory

depression, these drugs reverse the narcotic effect. Post No additional analgesia sign over bed. This prevents inadvertent analgesic overdosing.

Education/Continuity of Care

Provide anticipatory instruction on pain causes, appropriate prevention, and relief measures. Explain cause of pain or discomfort, if known. Instruct patient to report pain. Relief measures may be instituted. Instruct patient to evaluate and report effectiveness of measures used. Teach patient effective timing of medication dose in relation to potentially uncomfortable activities and prevention of peak pain periods. For patients on PCA or those receiving epidural analgesia: Teach patient preoperatively. Anesthesia effects should not obscure teaching. Teach patient the purpose, benefits, techniques of use/action, need for IV line (PCA only), other alternatives for pain control, and of the need

to notify nurse of machine alarm and occurrence of untoward effects.