Nursing Diagnoses for Mr. Harold: Impaired Mobility and Impaired Skin Integrity

This report focuses on the case scenario of Mr. Harold, an 83-year-old man with impaired mobility and impaired skin integrity. It discusses the nursing diagnoses, assessment, planning, implementation, evaluation, and discharge planning for Mr. Harold. The report also addresses the ethical and legal standards related to his care requirements.

Running head: NURSING
Nursing
Name of the student:
Name of the University:
Author’s note

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Introduction:
Patient engagement is an important part of patient centred care and to ensure continuity in
care, patient participation is critical during discharge planning (Bångsbo, Lidén & Dunér, 2014).
The five nursing process that is vital in patient centred care includes assessment, diagnosis,
planning, implementation and evaluation. Assessment is the first step involving data collection
related to subjective and objective data of patient. This is followed by nursing diagnosis using
appropriate clinical judgment to assist in care planning and implementation of care. The planning
stage involves development of nursing goals and outcome that influence patient care and
implementation involves stepwise steps taken to implement the nursing interventions outlined in
the care plan (Toney-Butler & Thayer, 2018). This report focussed on the case scenario of
Harold Blake, an 83 year old man who has been admitted to the hospital following an episode of
angina. His past medical history reveals past history of a left cerebral vascular accident and
angina, hypertension, dilated cardiomyopathy, hypercholesterolaemia and Gastro-oesophageal
reflux disorder (GORD). His lives with his wife and uses mobility device during movement and
shower. He is also dependent on one person for personal care. This report will use the above
mentioned five nursing process to identify two nursing diagnosed for Mr. Harold and discuss
about the rationale for referring to patient on multidisciplinary team members for his care. The
ethical and legal standards related to the care requirements for Mr. Harold will be discussed too.
Nursing Diagnosis 1: Impaired mobility
This section will give an insight into relevant nursing diagnoses for Mr. Harold using the
five nursing process.
Assessment:

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The review of subjective and objective data related to patient can help to conduct
assessment for Mr. Harold. The patient has been admitted to hospital following an episode of
angina when has another CVA (Cerebrovascular attack). His angina lasted for 29 minutes. His
past surgical history revealed bilateral hip replacement done for right leg 15 years ago and left
hip done 2 years ago. Other presenting symptom of Mr. Harold included chest tightness and
crushing pain in upper chest and shoulders. His socioeconomic data also suggest he is dependent
on one person for person care and movement. Impairment mobility is also understood from the
neurological observation for day 2 which indicates moderate weakness for right leg.
Diagnosis:
Based on the review of above objective data of Mr. Harold, it can be said that impaired
mobility is one of the nursing diagnoses for patient. This is because ageing, CVA and bilateral
hip replacement are all risk factor of impaired mobility and presence of all these condition in Mr.
Harold shows mobility impairment as major problem for patient. A CVA also termed as stroke
occurs when blood flow to the brain is disrupted due to a blocked artery. Patient age is the
strongest predictor of stroke. Logan et al. (2018) gives the evidence that for patients surviving a
stroke, decreased or impaired mobility occurs because of muscle weakness. For this reason,
patients with stroke are often immobile and they spend most of the time in chair and bed. As Mr.
Harold also survived a CVA, his chance of mobility impairment is high. Mr. Harold also
possesses other two risk factors for impaired mobility such as age and hip replacement surgery.
Mr. Harold is 83 years old and Brown and Flood (2013) supports that mobility limitation
increases at older age. In addition, hip replacement is one of the surgical risk factor for impaired
mobility as such patients are often advised to remain in bed and they suffer from restricted
mobility issues (). Hence, impaired mobility is the main diagnoses for Mr. Harold.

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Planning:
To reduce mobility impairment and reduce dependence on others for mobility, it is
planned to refer Mr. Harold to occupational therapist, speech pathologist and physiotherapist.
The role of these multiprofessional health care team is critical to provide appropriate mobility
support and exercise regimen to patient. Occupational therapy is critical for the rehabilitation of
patient as occupational therapist can aid in identifying dysfunctional areas and teaching patient’s
useful exercise to promote mobility and reduce dependence on mobility devices during personal
care and shower. In addition, the referral to physiotherapist will help the patient to safely return
to physical activity (Hoyer et al., 2016). The physiotherapist can play a role in providing
appropriate exercise on a daily basis to ensure that normal expected motion is achieved. Mr.
Harold is likely to walk with minimum difficulty once he adheres to the exercise regimen and
adapt to movement patterns taught by physiotherapist (Khalid et al., 2015). Physiotherapist’s
contribution in care is useful to ensure Mr. Harold achieves desired level of physical activity.
Implementation:
To further implement appropriate mobility related exercise for Mr. Harold, it is planned
to adapt strategies to promote mobility in patient. The first strategy is to develop appropriate
exercise schedule for Mr. Harold to help him mobilize with any device assistance or support
from one person. The collaboration of physiotherapist, nurse and patient is critical to ensure that
appropriate exercise schedule is made and patient adheres to the recommended timing of each
exercise. The significance of following exercise regimen is that it can patient to regain
movement and strength in the hip and prevent other problem associated with impaired mobility

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such as preventing sleep, improving balance, promoting sleep and increasing physical activity
(Skou et al., 2018).
Evaluation:
The evaluation of the effectiveness of the exercise regimen and collaboration with
physiotherapist and occupational therapist will be done by reassessment of movement and
mobility of Mr. Harold before discharge and ensuring that all desired goals and purpose of
intervention has been achieved or not.
Discharge planning:
As part of discharge planning, it is also planned to sent social worker to review Mr.
Harold’s house to identify whether his home environment increased any risk of fall or mobility
related issues for patient or not. The inspection of the house will help to understand whether any
environmental modification is needed or the exercise regimen can be followed in home or not.
Mr. Harold will also be advised to contact physiotherapist if there is confusion in following any
exercise regimen or if patients face any difficulty during discharge planning.
Ethical and legal standards to the care requirement:
In relation to the nursing diagnosis of impaired mobility, appropriate exercise regimen
and collaboration with occupational therapist and physiotherapist has been planned to promote
mobility for patient. However, before implementing this care plan, it is necessary to adhere to the
ethical and legal standard for consent regarding treatment. According to ethical code of conduct,
achieving informed consent from patient is critical before initiating any treatment of care plan.
However, as Mr. Blake condition is deteriorating neurologically, he may not be able to give

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informed consent for the same. Hence, in such case, consent needs to be taken from his family
members. One of the legal Act that is relevant to take appropriate decision regarding informed
consent included the Consent to Medical Treatment and Palliative Care Act 1995. The
significance of this act is that it gives direction regarding who can give consent to medical
treatment for adults and children during medical emergencies when person cannot give consent
(opa.sa.gov.au , 2019). Hence, appropriate person for informed consent can be identified before
implementing the exercise therapy for Mr. Harold.
Nursing diagnosis 2: Impaired skin integrity
Assessment:
Based on the review of neurological assessment for day2, it has been found that Glasgow
coma scale (GCS) for patient on day 2 is 12/15 as he obeys command, gives confused response
and obeys commands. His vital signs observation for day 2 revealed temperature of 26.3 degree
Celcius, heart rate of 62 beats per minute, respiratory rate of 20 bpm and BP 128/65. All the
parameters are normal however the patient is at high risk of blood pressure. The skin assessment
of patient at 1000 hours revealed red skin near the mouth and he is in bed because of mobility
related issues in right leg. Because of impaired mobility, he was also washed in bed with the
assistance of two nurses. Due to hip replacement surgery two years ago, Mr. Harold was also
experiencing weakness in leg.
Diagnosis:
Based on the analysis of above objective data of patient, it can be concluded that patient
is at risk of impaired skin integrity due to possibility of developing pressure ulcers. Pressure
ulcer is a condition that leads to localized damage to the skin and underlying tissue because of

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pressure, shear and friction (Guy, 2019). Mr. Harold is at risk of impaired skin integrity because
Mr. Harold has been continuously in bed since hospital admission and weakness in the right leg
has further increased the duration of bed rest. Hence, remaining in same position for prolonged
period can increase risk of pressure ulcer for patient. The main risk factors of pressure ulcer in
hospitalized adult patients include presence of chronic illness, staying in bed for longer period,
using chair and bed during daily activities and lack of position changes (Bereded, Salih &
Abebe, 2018). These risk factors were present for Mr. Harold too as he was suffering from
angina and he was also dependent on care activities like shower and eating. He washed in bed
indicating that was bedfast . Therefore, from the presence of risk factor of pressure ulcer in Mr.
Harold, it can be concluded that impaired skin integrity is the second nursing diagnoses for
patient.
Planning:
In response to the issue of impaired skin integrity, it is planned to enhance pressure
injury management by regular assessment of skin of patient, repositioning and implementing
appropriate pressure area care.
Implementation:
The role of nurse, physician and other support staff will be vital during implementation
of the plan. Nurse will play an important role in conducting skin assessment of patient and this
will help to predict skin’s reaction to pressure (Tayyib, Coyer & Lewis, 2015). Checking for
areas of localised heat, redness, skin breakdown and edema can help to identify the type of
pressure area care needed for Mr. Harold. Regular assessment of shoulders, knees, toes and
sacrum and heel is necessary as they are risk of pressure, friction and shearing forces. After

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appropriate pressure area is identified, the nurse can engage in skin care by keeping skin clean,
drying the skin to protect excess moisture and apply barrier cream in area with impaired skin
integrity.
In addition, positioning and repositioning of patient will be done by repositioning every
two hours. Pain management can also help to minimize risk of pressure injury. The advantage of
repositioning is that it reduces shear and friction forces on the skin (Moore & Cowman, 2015).
Evaluation:
To evaluate the outcome of above mentioned implementation strategy on promoting skin
integrity, it will be necessary to reassess skin of patient and detect improvement in relation to
signs of redness and skin breakdown. In addition, patient ability to reposition without any
assistance will also suggest success of the above care plan.
Multidisciplinary team and Discharge planning:
To ensure that Mr. Harold does not experience any skin integrity issue after discharge, it
is planned to discharge patient after referring to an occupational therapist. This is necessary to
because occupational therapist can educate patient about ways to manage symptoms and brings
changes to mobility pattern. The goal for discharge planning is to provide appropriate education
to patient and their family to ensure that they have clear understanding regarding the impact of
pressure area care and the benefit of following skin care advice to prevent pressure ulcer.
Legal and ethical planning:
As ethical dilemma related to patient dignity and privacy may occur during
implementation of care for pressure ulcer prevention, the relevant ethical standards that apply to

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the scenario includes following the ethical standard of beneficence. This involves the obligation
to do good for patient. This can be exercised during pressure ulcer care respecting individuality,
preserving dignity of patient and correctly using evidence based tool for assessment of skin
damage (Welsh, 2014). In addition, the Consent to Medical Treatment and Palliative Care Act
1995 is vital to ensure that consent for treatment can be taken from Mr. Harold’s family and
ethical issues related to informed consent (opa.sa.gov.au , 2019).
Conclusion:
From the use of five nursing process to identify two nursing diagnoses for Mr. Harold,
impaired mobility and risk of skin integrity has been identified as two major problem for patient.
In response to the problem of impaired mobility, the collaboration with physiotherapist and
occupational therapist was identified to promote mobile and reduce weakness in right limb. In
addition, as pressure ulcer risk was identified for Mr. Harold, the paper discussed about the
effectiveness of skin assessment and care and repositioning strategy to reduce pressure ulcer
occurring due to shear and friction. The application of relevant ethical and legal standard ensured
that no ethical issues can arise during implementation of the care plan.

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