Nursing Management
A holistic approach to caring for patients with multiple sclerosis (MS) involves caring for the body, mind, and emotional components of patients. Nursing care following research includes mobility, skin integrity, and continence checks. The primary focus for such a patient is skin integrity, given that incontinence and immobility predispose pressure ulcers. Her incontinence poses risks for a breakdown of skin to cause pressure sores or bed sores.
Central nursing interventions include:
- Nutritional Support: Encourage high-protein diets to contribute to recovery from wounds and general good health.
- Fall Prevention: Providing for safety in the environment, mobility assistance, and promoting strength exercise.
- Pain Management: Assessing pain regularly and adjusting pain management plans accordingly.
- Skin Care: Repositioning regularly, preventing moisture breakdown by applying barrier creams, and more frequent diaper changes (Tervo-Heikkinen et al., 2023).
Collaborative Health Care
Interprofessional collaboration is crucial in preventing pressure ulcers in patients who have MS. Because of incontinence and poor mobility; several health professionals maintain skin integrity and overall wellness. Physical therapists provide strength and flexibility, preventing immobility-related dangers, and promote frequent movement to prevent prolonged skin pressure. Occupational therapists assess the ability of the patient to perform daily living activities and prescribe assistive equipment, such as special mattresses and pressure-relief mattresses, to reduce skin breakdown.
Speech therapists assess swallowing disorders to avoid malnutrition, weakening skin, and impairing healing. Social workers offer emotional and financial assistance, including access to necessary supplies such as incontinence and barrier creams and access to local services for extra help. Case managers arrange for medical equipment, including pressure-relief mattresses, and ensure skin care interventions.
By working in collaboration, such professionals ensure protection strategies for skin, increased comfort, and reduced complications. The staff nurse is crucial in coordinating interventions, monitoring interventions, and educating the patient on skin care. Such collaboration assures an integrated approach to skin integrity, ultimately leading to quality-of-life improvement for the patient.
Head-to-Toe Assessment
| General Survey/Skin | Objective: Warm, dry skin with no rashes. |
| Subjective: Incontinence history is a risk factor that increases the chances of skin damage, even though the patient reports no itching issues. | |
| Head and Neck, Eyes, Ears, Nose, Throat | Objective: No abnormalities noted. |
| Subjective: No complaints | |
| Respiratory | Objective: Lungs clear to auscultation. |
| Subjective: No complaints of shortness of breath. | |
| Cardiovascular | Objective: Normal cardiovascular assessment. |
| Subjective: No chest pain and palpitations. | |
| Abdominal | Objective: Complaints of left lower quadrant pain. |
| Subjective: Reports occasional numbness in the leg. | |
| Elimination | Objective: History of incontinence |
| Subjective: Reports frequent accidents due to MS. | |
| Musculoskeletal | Objective: Normal range of motion. |
| Subjective: Reports difficulty with mobility and muscle weakness | |
| Neurological | Objective: Intact visual fields. |
| Subjective: Reports numbness in the leg | |
| Vital Signs/Pain | Objective: Stable vital signs. |
| Subjective: Abdominal pain present. | |
| Social, Cultural, Spiritual | Objective: Has two children and three grandchildren |
| Subjective: She expresses concerns about being a burden to her family. | |
| Erickson’s Developmental Tasks | |
| The patient is in the stage of Integrity vs. Despair in Erikson’s psychosocial development theory. This patient might have trouble coping with feelings of reliance on other people and lack of autonomy caused by her MS (Orenstein & Lewis, 2022). | |
| Maslow’s Hierarchy of Needs | Maslow’s Hierarchy of Needs The patient’s immediate requirements are: Physiological Needs: Management of incontinence and pain Safety Needs: Preventing falling and protecting skin integrity. Belongingness Needs: Emotional support from family. |
Nursing Process
| Analyze your head-to-toe assessment findings in the section above. List three abnormal findings. Incontinence, increasing the likelihood of breakdown of skin. Chronic pain in the lower left side that affects daily living. Limited mobility due to MS that leads to fall risk (Montero-Odasso et al., 2022). Determine a priority concern for your resident. Explain why you chose this: The primary focus for this client is to stop skin breakdown as a result of incontinence and prolonged immobility. The client, secondary to multiple sclerosis (MS), cannot mobilize on his or her own and thus is applying pressure to skin areas. Incontinence exacerbates the risk by keeping skin wet, and skin irritation and breakdown develop. These conditions, if left unchecked, may progress to slow healing, painful pressure ulcers, and may lead to infections. To prevent such, regular repositioning, dryness, and application of protective barrier creams in nursing care is crucial. The integrity of the skin is crucial in maintaining the health, quality of life, and comfort of the patient. Prevention of skin complications and promotion of healing is through timely detection of skin problems, regular skincare, and interventions (Montero-Odasso et al., 2022). |
| Create a plan related to your priority concern. What is the goal? What outcome are you striving for to promote, maintain, or restore your resident’s health? Be specific and discuss outcomes you believe are obtainable during your 4-week clinical experience. It should be something you can do or assist with as a student nurse. Care Plan and Goals The primary goal is to maintain skin integrity by preventing pressure sores. Due to incontinence and lack of movement, she is at serious risk of developing painful sores and subsequent infections and complications. The course of treatment is to reposition frequently, keep skin adequately moist, and keep skin properly hygienic. Repositioning the person every two hours is also required to take pressure off sensitive areas, promote circulation, and reduce the risk of ulcers. Control of moisture is accomplished by frequent incontinence product changes, application of absorbency pads, and application of skin protection creams to maintain skin free of irritation. Maintenance of skin dryness and cleanliness through good hygiene is also required to promote skin health and healing. In addition, good nutrition and fluids will also contribute to skin health and healing. Expected Outcomes: The patient’s skin is clear and free of any evidence of breakdown. Moisture levels are properly regulated to avoid irritation. The patient feels greater comfort and better hygiene. By implementing such practices, skin harm is prevented, healing is accelerated, and general health is maximized for the individual. Adjustments and frequent evaluation ensure continued effectiveness in skin maintenance. |
| Take action. Determine three nursing interventions that address your priority concern and provide a rationale on how the interventions promote your resident’s health. Discuss how they will be implemented. These should come from a medical reference. Nursing Interventions Skin Care Management Check the skin on a daily basis for redness, sores, or irritation. Reposition the patient every two hours to relieve sensitive areas. Use moisture-absorbing materials and barrier creams to dry and protect skin (Campbell & Samolyk, 2020). Rationale: Pressure ulcers, common in incontinent and bedridden individuals, are prevented by frequent repositioning and moisture control. Hygiene and Moisture Control Change incontinence underwear daily to keep yourself dry. Keep the skin dry and clean by using soft towels and gentle cleansers. Encourage adequate fluid intake to ensure skin moisture and overall health. Rationale: Proper hygiene reduces irritation, prevents infections, and promotes overall skin health. Mobility Support and Comfort Assist with transfers by using safe body mechanics to prevent skin shearing. Engage the patient in light physical activity to stimulate circulation. Use pressure-relieving mattresses and cushioning to reduce prolonged skin contact against surfaces. Rationale: Supporting mobility reduces prolonged skin pressure, boosts circulation, and enhances overall health. |
| Evaluate the effectiveness of each intervention for your priority assessment concern. Did the intervention promote, maintain, or restore health? Effectiveness of Interventions Skin Care Management Regular repositioning and moisture control effectively relieved skin irritation and prevented pressure sores. The skin on the patient stayed intact, and no breaks or sores appeared. Continuous monitoring made early redness detection possible, thus enabling timely intervention. Hygiene and moisture control Frequent changes of incontinence garments and application of skin protection creams kept the skin dry and safe. Hygiene practices minimized irritation and kept infections under control, and healthy skin ensued (Campbell & Samolyk, 2020). Mobility Support and Comfort Using pressure-relieving cushions and transfers relieved prolonged pressure on sensitive tissues. Encouraging light activity helped to improve circulation and skin integrity. The patient complained less and reported greater comfort and less discomfort due to prolonged immobility. |
| Evaluate the overall progression towards the goal for your priority concern for your assigned resident. Was the goal achieved? Why or why not? Would you keep this goal or change it? The goal of maintaining skin integrity was achieved to some extent. The repositioning and moisture control did not allow any development of new pressure ulcers, and the skin of the patient remained healthy. Redness and light irritation were evident on occasions, and hence, regular monitoring and adjustment in treatment strategies were required. The use of incontinence supplies, barrier creams, and better hygiene practices helped to minimize skin irritation and reduce infection. Mobility promotion also benefited circulation and helped to maintain skin health. As the general situation is better, there is nonetheless a challenge in preventing skin irritation altogether. Moving forward, skin integrity is always kept a priority, but in addition, fine-tuning skincare interventions, optimizing repositioning regimens, and education on the maintenance of moisture and hygiene are crucial. Re-assessments and individual adjustments on an ongoing basis will provide better overall health and quality of life for the patient. |
References
Campbell, J., & Samolyk, M. (2020). Skin injury prevention and treatment in the older person: Reframing our approach in the community. British journal of community nursing, 25(Sup9), S6-S26. https://www.magonlinelibrary.com/doi/abs/10.12968/bjcn.2020.25.Sup9.S6
Montero-Odasso, M., Van Der Velde, N., Martin, F. C., Petrovic, M., Tan, M. P., Ryg, J., & Masud, T. (2022). World guidelines for falls prevention and management for older adults: A global initiative. Age and Ageing, 51(9), afac205. https://academic.oup.com/ageing/article-pdf/51/9/afac205/52209676/afac205.pdf
Motl, R. W. (2020). Exercise and multiple sclerosis. Physical Exercise for Human Health, 333–343. https://www.awin1.com/cread.php?pref1=groobox.com&awinmid=26429&awinaffid=685769&clickref=lb_mv8b3b0-0-groobox.com&p=https%3A%2F%2Flink.springer.com%2Fchapter%2F10.1007%2F978-981-15-1792-1_22
Orenstein, G. A., & Lewis, L. (2022). Eriksons stages of psychosocial development. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556096/
Soe, Y. N. (2024). Nursing interventions to prevent pressure injuries among elderly residents in nursing homes. https://www.theseus.fi/bitstream/handle/10024/856224/Yee_Soe.pdf?sequence=2
Tervo-Heikkinen, T., Heikkilä, A., Koivunen, M., Kortteisto, T., Peltokoski, J., Salmela, S., & Junttila, K. (2023). Nursing interventions in preventing pressure injuries in acute inpatient care: A cross-sectional national study. BMC nursing, 22(1), 198. https://link.springer.com/content/pdf/10.1186/s12912-023-01369-8.pdf
