[Daytonite]

Originally Posted by CapeCoralChick

Hi everyone, I just wanted to thank you all again for the help. This is my first care plan. Quick version: A 20 yr old in traction for 3 weeks on bedrest.

My first diagnosis is Impaired tissue integrity/ or would skin sound better.

I was wondering if related to surgical procedure is ok??

And AEB- presence of insicion..... (I'm confused on what manifestations I should use for a surgical incision)

I just really need to get a good understanding. I'm going to sit down with some books tonight after I put my baby to bed.

First order of business in developing a care plan is to assemble the data that you collected on the patient. You are going to be most interested in the abnormal data for developing a care plan. If you've assessed the patient using Maslow, Gordons Functional Health Patterns, Roper/Logan/Tierney's Activities of Living or some other listing your instructors have given you, you are going to find those abnormal data items there. So, from a nursing point of view, what are this patient's symptoms (abnormal data)? Does he/she have any of these: pain, constipation, skin breakdown, self-care deficits such as difficulty with eating, bathing, toileting, or dressing?

You want to take these patient's symptoms and put them on a list. Start looking to see if any of them kind of stick out as kind of belonging together to form a problem the patient is having that you, the nurse, can treat.

Using Impaired Tissue Integrity

For example, if the patient has several reddened bony prominences where pieces and parts of his/her body is contacting the mattress, then you have the evidence to support a nursing diagnosis of Impaired Tissue Integrity.

Your "related to" part of your diagnostic statement has to do with what is causing the symptoms. So, is the reddened skin due to:

• mechanical factors such as pressure, shearing forces or friction
• nutritional deficits
• chemical irritants (docy excretions, secretions, medications)
• impaired physical mobility
• altered circulation
• a fluid deficit or excess

The above items can be used as "related to" factors with Impaired Tissue Integrity. Now, just think about this a minute. How is a surgical procedure the cause of the patient's Impaired Tissue Integrity? The NANDA definition of this particular diagnosis is: Damage to mucus membrane, corneal, integumentary or subcutaneous tissues. To my way of thinking, an incision is a medical intervention and treatment, not damage. In actuality, this particular diagnosis is more appropriately used for stasis ulcers or damage to skin that occurs from bedrest, lying on tubes or other medical devices. There is another diagnosis to cover the incision that will be more appropriate.

Moving On. . .
What is your physical assessment of this patient's incision? Are there any signs or symptoms of infection? If so, what are they? If he has a temperature, there is a nursing diagnosis to cover that. If not, you can still use the nursing diagnosis of Risk for Infection. That is always an appropriate nursing diagnosis to use with a newly post-op surgical patient.

Once you know what your patient's symptoms are and have them all appropriate grouped under the correct nursing diagnoses, your next step is to develop nursing interventions for each of the symptoms. That part is really not the hard part since you can readily find nursing interventions in your nursing textbooks. What you are stuck with is the nursing diagnosis and the nursing diagnosis statement.

Here are possible nursing diagnoses that would be related to a patient in traction. Does any of your assessment data look like it might fit into any of these diagnostic categories?

• Acute Pain R/T immobility, injury or disease AEB (your assessment data)
• Constipation R/T immobility AEB (your assessment data)
• Impaired Physical Mobility R/T imposed bedrest AEB traction
• Ineffective breathing pattern R/T inability to deep breath in supine position AEB (your assessment data: decreased, diminished respirations or other signs of struggling to breath) NOTE: pulmonary embolism is ALWAYS a risk factor in bedrest patients!
• Ineffective Tissue Perfusion R/T interruption of venous flow AEB (your assessment data: edema, weak pulses, skin color or temperature changes in the elevated extremity, altered sensations, cold extremity)
• Self-Care Deficit: feeding, dressing/grooming, bathing/hygiene, toileting R/T degree of impaired physical mobility or body area affected by traction AEB (your assessment data)
• Powerlessness R/T forced immobility in health care environment AEB (your assessment data: fluctuating behavrior, nonparticipation in care, anger, passivity, irritability, fear of alienation, expressions of frustrations because of inability to perform ADLs or of having no control over care)
• Risk for Impaired Skin Integrity R/T contact of traction equipment with the skin AEB (your assessment data)
• Risk for Disuse syndrome R/T mechanical immobilization AEB (your assessment data)
• Impaired Transfer ability R/T presence of traction AEB (your assessment data)
  Risk for Infection R/T Invasive procedure [surgery] AEB (your assessment data: environmental exposure to pathogens, immunosuppression, malnutrition, suppressed inflammatory response, chronic disease)

Since this is a first care plan and a surgical orthopedic patient as well, go with the most obvious and important things. Are you allowed to use potential nursing diagnoses, the ones that begin with the words "Risk"? If so, this is the way and order of priority I would go. Remember, I really don't know this patient like you do. I am basing this on my years of experience in nursing, but I'm sure I've given you a great deal to think about!

1. Acute Pain R/T immobility, injury or disease AEB (your assessment data)
2. Self-Care Deficit: feeding, dressing/grooming, bathing/hygiene, toileting R/T degree of impaired physical mobility or body area affected by traction AEB (your assessment data)
3. Constipation R/T immobility AEB (your assessment data)
4. Risk for Infection R/T Invasive procedure [surgery] AEB (your assessment data: environmental exposure to pathogens, immunosuppression, malnutrition, suppressed inflammatory response, chronic disease)
5. Risk for Impaired Skin Integrity R/T contact of traction equipment with the skin AEB (your assessment data)

Post any other questions you have with the construction of this careplan to this thread. I will keep my eye open and hope my telephone line (I only have a dial up connection) is being cooperative today. Others are encouraged to chime in here as well.