Scleroderma Nursing Diagnosis & Care Plan

Scleroderma, also known as systemic sclerosis, is a complex autoimmune connective tissue disorder characterized by the hardening and tightening of the skin and connective tissues. This condition can affect various body systems, including the skin, blood vessels, digestive tract, and internal organs.

Nursing care for patients with scleroderma is crucial in managing symptoms, preventing complications, and improving quality of life.

Causes (Related to)

Scleroderma results from an overproduction and accumulation of collagen in body tissues. While the exact cause is unknown, several factors may contribute to its development:

• Genetic predisposition
• Environmental triggers
• Immune system dysfunction
• Vascular abnormalities
• Hormonal influences

Signs and Symptoms (As evidenced by)

Scleroderma can manifest with a variety of signs and symptoms. During a physical assessment, a patient with scleroderma may present with one or more of the following:

Subjective: (Patient reports)

• Joint pain and stiffness
• Raynaud’s phenomenon (color changes in fingers and toes in response to cold or stress)
• Difficulty swallowing
• Shortness of breath
• Fatigue
• Gastrointestinal issues (heartburn, bloating, constipation)

Objective: (Nurse assesses)

• Skin thickening and tightening, especially on hands and face
• Telangiectasias (dilated blood vessels near the skin surface)
• Digital ulcers
• Calcinosis (calcium deposits in the skin)
• Sclerodactyly (skin tightening of the fingers)
• Microstomia (narrowing of the mouth opening)
• Pulmonary hypertension
• Interstitial lung disease
• Renal crisis (sudden onset of high blood pressure and kidney failure)

Expected Outcomes

The following are common nursing care planning goals and expected outcomes for scleroderma:

• The patient will report improved management of Raynaud’s phenomenon symptoms
• The patient will demonstrate increased joint mobility and reduced pain
• The patient will maintain adequate nutrition and report improved swallowing ability
• The patient will exhibit improved skin integrity and reduced risk of digital ulcers
• The patient will report the enhanced ability to perform activities of daily living
• The patient will demonstrate effective coping strategies for managing chronic illness

Nursing Assessment

1. Conduct a comprehensive skin assessment
   Evaluate the extent of skin involvement, noting areas of thickening, tightening, and ulcerations. This helps track disease progression and identify potential complications.
2. Assess joint mobility and function.
   Examine a range of motion in all joints, particularly in the hands and fingers. Limited mobility can impact daily activities and quality of life.
3. Evaluate respiratory status
   Monitor respiratory rate, depth, and effort. Assess for signs of pulmonary hypertension or interstitial lung disease, such as dyspnea or decreased oxygen saturation.
4. Assess gastrointestinal function
   Inquire about difficulty swallowing, reflux symptoms, and changes in bowel habits. GI involvement is common in scleroderma and can lead to nutritional deficiencies.
5. Monitor cardiovascular status
   Check blood pressure regularly and assess for signs of Raynaud’s phenomenon. Cardiovascular complications are a significant concern in scleroderma.
6. Evaluate renal function
   Monitor urine output, serum creatinine, and blood pressure for signs of scleroderma renal crisis.
7. Assess psychosocial status
   Evaluate the patient’s emotional well-being, coping mechanisms, and support systems. Chronic illness can have significant psychological impacts.
8. Review medications and treatments.
   Assess current medications’ effectiveness and side effects, including immunosuppressants, vasodilators, and symptom-specific treatments.

Nursing Care Plans

Care Plan 1: Impaired Skin Integrity

Nursing Diagnosis Statement:
Impaired Skin Integrity related to collagen overproduction and vascular changes secondary to scleroderma as evidenced by skin tightening, digital ulcers, and telangiectasias.

Related factors/causes:

• Autoimmune-mediated fibrosis of the skin
• Vascular insufficiency
• Decreased mobility

Nursing Interventions and Rationales:

1. Perform daily skin assessments, focusing on areas prone to breakdown.
   Rationale: Early detection of skin changes allows for prompt intervention and prevention of complications.
2. Implement a gentle skincare routine using lukewarm water and mild, fragrance-free moisturizers.
   Rationale: Proper skin care helps maintain skin integrity and prevents further drying and cracking.
3. Teach and encourage range of motion exercises for affected joints.
   Rationale: Regular movement helps maintain skin flexibility and prevents contractures.
4. Apply protective dressings to existing ulcers and pressure points.
   Rationale: Appropriate wound care promotes healing and prevents infection.
5. Educate the patient on the importance of avoiding extreme temperatures and protecting the skin from trauma.
   Rationale: Temperature extremes and minor injuries can exacerbate Raynaud’s phenomenon and lead to ulcer formation.

Desired Outcomes:

• The patient will demonstrate improved skin integrity within two weeks.
• The patient will report the decreased incidence of Raynaud’s attacks within one month.
• The patient will exhibit proper skincare techniques by the end of the education session.

Care Plan 2: Ineffective Breathing Pattern

Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to pulmonary fibrosis secondary to scleroderma as evidenced by dyspnea, decreased oxygen saturation, and limited chest expansion.

Related factors/causes:

• Interstitial lung disease
• Pulmonary hypertension
• Chest wall tightening

Nursing Interventions and Rationales:

1. Assess respiratory rate, depth, and effort every 4 hours.
   Rationale: Regular monitoring helps detect early signs of respiratory deterioration.
2. Position the patient in a semi-Fowler’s or high Fowler’s position.
   Rationale: Upright positioning promotes optimal lung expansion and eases breathing effort.
3. Teach and practice pursed-lip breathing and diaphragmatic breathing techniques.
   Rationale: These techniques help improve oxygenation and reduce the work of breathing.
4. Administer oxygen therapy as prescribed and monitor oxygen saturation.
   Rationale: Supplemental oxygen helps maintain adequate tissue oxygenation.
5. Collaborate with respiratory therapy for pulmonary function tests and chest physiotherapy.
   Rationale: Regular pulmonary assessment and airway clearance techniques help manage respiratory symptoms.

Desired Outcomes:

• The patient will demonstrate improved breathing patterns within one week.
• The patient will maintain oxygen saturation >92% on room air within two weeks.
• The patient will verbalize understanding of breathing techniques by the end of the education session.

Care Plan 3: Imbalanced Nutrition: Less than Body Requirements

Nursing Diagnosis Statement:
Imbalanced Nutrition: Less than Body Requirements related to difficulty swallowing and gastrointestinal dysmotility secondary to scleroderma as evidenced by unintentional weight loss and early satiety.

Related factors/causes:

• Esophageal dysmotility
• Gastroesophageal reflux disease (GERD)
• Microstomia (narrowing of the mouth opening)

Nursing Interventions and Rationales:

1. Assess nutritional status, including weight, dietary intake, and laboratory values.
   Rationale: Comprehensive nutritional assessment helps identify specific deficiencies and guide interventions.
2. Collaborate with a dietitian to develop a tailored meal plan.
   Rationale: A specialized diet can address nutritional needs while accommodating swallowing difficulties.
3. Teach and encourage proper positioning during and after meals (upright for at least 30 minutes).
   Rationale: Proper positioning helps reduce reflux and improves swallowing.
4. Provide small, frequent meals and soft or pureed foods as tolerated.
   Rationale: Smaller meals are easier to swallow and digest for patients with GI involvement.
5. Administer prescribed medications for GERD and motility issues.
   Rationale: Pharmacological management can improve GI symptoms and enhance nutritional intake.

Desired Outcomes:

• The patient will demonstrate weight stability or gain within one month.
• The patient will report improved ability to swallow and reduced GERD symptoms within two weeks.
• The patient will verbalize understanding of dietary modifications by the end of the education session.

Care Plan 4: Chronic Pain

Nursing Diagnosis Statement:
Chronic Pain related to joint inflammation and skin tightening secondary to scleroderma as evidenced by patient reports of persistent pain and limited mobility.

Related factors/causes:

• Musculoskeletal involvement
• Peripheral neuropathy
• Raynaud’s phenomenon

Nursing Interventions and Rationales:

1. Assess pain characteristics, intensity, and impact on daily activities using a standardized pain scale.
   Rationale: Comprehensive pain assessment guides appropriate management strategies.
2. Administer prescribed pain medications as ordered and evaluate their effectiveness.
   Rationale: Proper pain management improves quality of life and functional ability.
3. Apply warm compresses to affected joints and teach proper technique for home use.
   Rationale: Heat therapy can help reduce joint stiffness and improve circulation.
4. Teach and encourage regular gentle exercises and stretching routines.
   Rationale: Physical activity helps maintain joint flexibility and reduces pain.
5. Explore and teach non-pharmacological pain management techniques (e.g., relaxation, mindfulness).
   Rationale: Complementary techniques can enhance pain control and reduce reliance on medications.

Desired Outcomes:

• The patient will report decreased pain intensity (by at least 2 points on the pain scale) within two weeks.
• The patient will demonstrate increased joint mobility within one month.
• The patient will utilize at least two non-pharmacological pain management techniques by the end of the education session.

Care Plan 5: Ineffective Coping

Nursing Diagnosis Statement:
Ineffective Coping related to the chronic and progressive nature of scleroderma as evidenced by expressed feelings of helplessness and anxiety about the future.

Related factors/causes:

• Unpredictable disease course
• Physical limitations
• Altered body image

Nursing Interventions and Rationales:

1. Assess the patient’s understanding of scleroderma and its management.
   Rationale: Identifying knowledge gaps allows for targeted education and support.
2. Provide education about the disease process, treatment options, and self-management strategies.
   Rationale: Accurate information empowers patients to actively participate in their care.
3. Encourage expression of feelings and concerns about living with scleroderma.
   Rationale: Emotional support helps patients process their experiences and develop coping strategies.
4. Refer to support groups and mental health professionals as appropriate.
   Rationale: Peer support and professional counseling can enhance coping skills and emotional well-being.
5. Teach stress management techniques, such as deep breathing and progressive muscle relaxation.
   Rationale: Stress reduction techniques can help manage both physical symptoms and emotional distress.

Desired Outcomes:

• The patient will verbalize an improved understanding of scleroderma and its management within one week.
• The patient will demonstrate the use of at least two coping strategies within two weeks.
• The patient will express feelings of increased control over their condition within one month.

References

1. Denton, C. P., & Khanna, D. (2017). Systemic sclerosis. The Lancet, 390(10103), 1685-1699. https://doi.org/10.1016/S0140-6736(17)30933-9
2. Hinchcliff, M., & Varga, J. (2019). Systemic Sclerosis/Scleroderma: A Treatable Multisystem Disease. American Family Physician, 99(10), 617-624.
3. Kowal-Bielecka, O., Fransen, J., Avouac, J., Becker, M., Kulak, A., Allanore, Y., … & Matucci-Cerinic, M. (2017). Update of EULAR recommendations for the treatment of systemic sclerosis. Annals of the Rheumatic Diseases, 76(8), 1327-1339. https://doi.org/10.1136/annrheumdis-2016-209909
4. Mouthon, L., Mehrenberger, M., Teixeira, L., Furst, D. E., Czirják, L., Chizzolini, C., … & Allanore, Y. (2020). Scleroderma renal crisis: Risk factors, diagnosis and treatment. Nature Reviews Rheumatology, 16(12), 678-694. https://doi.org/10.1038/s41584-020-0513-2
5. Saketkoo, L. A., & Distler, O. (2020). Is there evidence for vasculitis in systemic sclerosis? Current Opinion in Rheumatology, 32(6), 527-534. https://doi.org/10.1097/BOR.0000000000000734
6. van den Hoogen, F., Khanna, D., Fransen, J., Johnson, S. R., Baron, M., Tyndall, A., … & Pope, J. E. (2013). 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis & Rheumatism, 65(11), 2737-2747. https://doi.org/10.1002/art.38098