Video Case Study - Integumentary System and Mucous Membranes

Nurse Yoko works in a long-term care facility and is caring for Penny, a 79-year-old female, who was recently admitted with a history of a stroke with left-sided peripheral neuropathy and weakness. After introducing herself to Penny, Nurse Yoko goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Penny's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Yoko recognizes important cues, including findings from her assessment of Penny's skin, oral mucous membranes, and nails, as well as her functional ability. Nurse Yoko notes Penny has dry, cracked lips and a yellow-brown film on her teeth. On her lower extremities, Nurse Yoko notes dry, flaky skin, and after removing her socks, she sees that Penny has thick, discolored toenails and a pressure injury on her left heel.

Nurse Yoko asks Penny about her activities of daily living, or ADLs.

Nurse Yoko: Penny, can you tell me a little bit about how you've been doing with your daily routine?

Penny: I'm used to being able to care for myself, but after the stroke, it's been hard for me to do things I used to do.

Nurse Yoko: I understand. Can you tell me what sort of things you used to do that you aren't doing now?

Penny: Well, I'm left-handed but now that my left arm is weak, it's hard for me to brush my teeth and clean myself up. I can't even cook a meal for myself anymore.

Nurse Yoko: That must be difficult. I also noticed you have a pressure injury on your left heel. How long has it been there?

Penny: I have numbness and weakness in my left leg and it's hard for me to move around. One day I bumped the back of my foot, and the sore hasn't healed since. I didn't even notice it was there until days later.

Next, Nurse Yoko analyzes these cues. She reviews Penny's electronic health record, or EHR, and notes that although she can walk short distances, she's been using a wheelchair to move around the facility. In the progress note from the occupational therapist, Nurse Yoko reads that Penny requires moderate assistance with ADLs and that she has moderate muscle strength and tone in her right hand and poor strength and tone in her left hand.

Now, using the information gathered, Nurse Yoko chooses a priority hypothesis of self-care deficit.

Then, she generates solutions to address Penny's self-care needs and she establishes the expected outcome that after intervening, Penny will participate in bathing once per day and oral care twice per day.

Nurse Yoko then takes action to implement these solutions. She gathers the supplies for bathing and oral care and asks the unlicensed assistive personnel, or UAP, to assist her. Together, Nurse Yoko and the UAP assist Penny to a chair in the bathroom.

Since Penny can use her right hand, Nurse Yoko encourages her to clean her own face and chest with a wet washcloth while Nurse Yoko and the UAP clean her back and legs. Afterwards, the UAP rubs moisturizer into Penny's skin while Nurse Yoko applies the ordered dressing to Penny's heel.

After Penny is dressed, Nurse Yoko assists her to brush her own teeth.

Penny: Can't you do this for me? I don't like using my right hand, it doesn't feel natural.

Nurse Yoko: I know, but I want you to try, so you do more of the things you used to do.

Penny: Okay, it would be nice to feel like myself again.

Penny proceeds to brush her top teeth but stops before moving to her bottom teeth.

Penny: I'm too tired to brush my bottom teeth.

Nurse Yoko: I can help you with that. You did a great job with the top ones. I know it can get tiring.

Following oral care, Nurse Yoko and the UAP settle Penny in her bed. Penny thanks them both for their help and reports that she feels much better. Nurse Yoko knows that Penny's skin integrity could be further compromised if she becomes dehydrated or malnourished, so she assists Penny to order a lunch tray rich in protein and other nutrients. Lastly, since Penny's nails are thick and dry, Nurse Yoko recommends a podiatry consult.

Later that evening, Nurse Yoko evaluates the outcome of her actions. During her repeat assessment, she notices that Penny's skin looks clean and feels soft, and that her dressing is dry and intact. Also, Penny's lips are warm and moist, and her teeth remain clean.

Alright, as a quick recap…. Nurse Yoko recognized and analyzed cues related to Penny's self-care deficit, prioritized hypotheses and generated solutions to address this problem. She then implemented measures to address Penny's hygiene and skin integrity and evaluated the outcomes, comparing them to the expected outcomes. Since Penny was able to participate in bathing and oral care, Nurse Yoko determined that the plan of care was successful.

Clinical Judgment Measurement Model

Patient: Penny, 79-year-old female | Long-term care facility Admitting diagnosis: Stroke with left-sided peripheral neuropathy and weakness Nurse: Nurse Yoko

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Step 1 — Recognize Cues

Objective Findings

System	Finding
Oral mucous membranes	Dry, cracked lips; yellow-brown film on teeth
Skin — lower extremities	Dry, flaky skin
Nails	Thick, discolored toenails
Left heel	Pressure injury present
Mobility	Uses wheelchair; can walk short distances
Left upper extremity	Weak (dominant hand); poor strength and tone
Right upper extremity	Moderate strength and tone

Subjective Findings

• Penny reports difficulty performing ADLs due to left-sided weakness
• Reports numbness and weakness in left leg → delayed detection of heel wound ("didn't even notice it was there until days later")
• States brushing teeth feels unnatural with non-dominant right hand

Chart Review

• OT progress note: requires moderate assistance with ADLs
• Left hand: poor strength and tone | Right hand: moderate strength and tone

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Step 2 — Analyze Cues

Cue Cluster	Clinical Significance
Left-sided weakness + neuropathy	Impairs self-care ability (bathing, oral care, mobility)
Dry, cracked lips + film on teeth	Inadequate oral hygiene
Pressure injury on heel	Consequence of immobility + sensory deficit
Thick, discolored toenails	Possible onychomycosis; risk for skin breakdown
Wheelchair dependence	Prolonged pressure → pressure injury risk
Poor nutrition risk	Dehydration and malnutrition worsen skin integrity

Key connection: Left-sided peripheral neuropathy → reduced sensation → inability to detect injury → delayed wound healing → further skin integrity compromise.

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Step 3 — Prioritize Hypotheses

Hypothesis	Priority	Rationale
Self-Care Deficit	✅ Priority	Inability to independently perform bathing and oral care leads to skin and mucous membrane compromise
Impaired Skin Integrity	Secondary	Active pressure injury on heel; at risk for further breakdown
Risk for Infection	Tertiary	Pressure injury + poor oral hygiene increase infection risk

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Step 4 — Generate Solutions

Goal (Expected Outcome): After intervening, Penny will participate in bathing once per day and oral care twice per day.

Planned Interventions

• Assist with bathing daily; involve UAP
• Encourage use of right (stronger) hand for self-care to maintain independence
• Perform oral care twice daily
• Apply ordered dressing to left heel pressure injury
• Apply moisturizer to dry skin after bathing
• Provide high-protein diet to support wound healing and skin integrity
• Initiate podiatry consult for thick, discolored toenails

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Step 5 — Take Action

Bathing

1. Gathered bathing and oral care supplies
2. UAP assisted — Penny cleaned face and chest using right hand independently
3. Nurse Yoko and UAP cleaned back and legs
4. UAP applied moisturizer to skin
5. Nurse Yoko applied ordered dressing to left heel

Oral Care

1. Assisted Penny to brush top teeth independently (right hand)
2. When Penny reported fatigue before bottom teeth, nurse assisted with remainder
3. Reinforced encouragement: "You did a great job with the top ones."

Nutrition

• Assisted Penny to order a high-protein lunch tray to promote skin integrity

Referrals

• Recommended podiatry consult for nail assessment and care

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Step 6 — Evaluate Outcomes

Expected Outcome	Result
Participate in bathing once per day	✅ Met — skin clean, soft; dressing dry and intact
Participate in oral care twice per day	✅ Met — lips warm and moist; teeth clean

Determination: Plan of care successful. Penny actively participated in both bathing and oral care with appropriate assistance.

Ongoing Monitoring

• Continue daily skin assessments, particularly over bony prominences
• Monitor pressure injury healing trajectory
• Encourage progressive independence with ADLs as strength allows
• Ensure adequate hydration and nutrition to prevent further skin compromise