About
Connective tissue disorder involving the skin, organs, and blood vessels causing edema, collagen accumulation, and eventually dysfunction of the areas inhabited by tough, immovable tissue.
Assess
Reddened, dry skin, edema, tough skin surfaces, immovable skin areas progressing to extremity stiffness and immobility, and finally heart failure, renal failure, digestive disorders, and respiratory compromise.
Complications
Heart failure, respiratory failure, renal failure, GI disturbances and malfunction
Diagnosis
- Impaired skin integrity related to connective tissue changes.
- Self care deficit related to immobility.
- Nutrition less than body requirements related to esophageal stiffening and digestive complaints.
- Body image disturbance related to collagen accumulation and facial erythema.
- Decreased cardiac output related to left ventricular failure.
- Impaired gas exchange related to stiffening of the lung walls.
Goals
- The client will be able to describe interventions to prevent further skin irritation.
- The client will demonstrate thorough skin assessments to monitor for skin breakdown.
- The client will maintain adequate support systems.
- The client will verbalize feelings related to disease and prognosis.
- The client will maintain good caloric intake.
- The client will participate with ADL's as much as able.
- The client identify steps to complete advanced directives.
Interventions
- Assess and monitor skin areas for changes and breakdown.
- Monitor swallowing ability.
- Protect the hands and feet from extreme weather conditions.
- Encourage client to wear well-fitting shoes to prevent foot ulcers.
- Encourage client to quit smoking.
- Assist with ADL's as needed and as disease progresses.
- Encourage high calorie fortified foods.
- Provide opportunities for client to discuss feelings related to disease and prognosis.
- Provide support and encourage client to maintain a good support system.
- Address issues related to end-of-life care and wishes regarding medical intervention and treatment toward the end-of-life.
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