Impaired Tissue Integrity

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    I think I'm losing my mind because I can not seem to figure this one part of my care plan out tonight. Just some history, we do FULL care plans (10-15 pages each week) all semester for every patient. It usually takes on average 10-20 hours to produce something decent. So trust me when I say that I'm not just trying to get the answers without looking.

    Okay, my patient is in the hospital for a Decub Ulcer on his sacral coccyx (stage 3). He also has dementia, alzheimers, DM, HTN, urosepsis, GERD, COPD, depression, anemia, seizures and a whole host of other problems. Primarily what I'm dealing with though is the decub.

    So, using Impaired Skin Integrity as my NANDA ... my goal is "the patient will demonstrate progressive healing of tissue by discharge" .. but what is my "as evidenced by"? I can come up with goals and rationales but the AEB is killing me. The wound is covered by Tegasorb so I haven't even seen it in the past two days as the nights have been changing it. Can anyone help with the AEB part?

    Thanks for any help/suggestions/funny stories .... my head and neck are killing me!
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  3. 3 Comments so far...

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    The AEB is what is happening with the wound.

    AEB 4cm x 3 cm Stage III breakdown on coccyx.
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    P_RN,

    Thanks for the reply ... yes, I have that part down as my Nursing Diagnosis but what I'm looking for is the goal combined with the AEB. Our care plans are long and complicated ... the mroe I do them the more I'm jealous of those with abbreviated or just a few care plans a semester. Anyway, I have the Nursing Diagnosis, the nursing system, the symptoms and such but I need specific goals ... I'm thinking "wound will have granular tissue present" or "wound will decrease in size" or something like that. I guess I just don't know how to say it ... but thank you so much for trying to help me!

  6. 0
    Decreased drainage, presence of pink granulation tissue, decrease in deepth or size of wound. All the things you'd look for when trying to heal a wound. I would give it a two week time period. Good luck on the care plan.


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