Care plan help, please - page 2

Hi all, I'm working on a care plan for my second week of clinicals this Thursday and Friday, and I could use some help prioritizing my top five diagnoses. My pt has a G-tube, indwelling... Read More

  1. by   Daytonite
    honestly, it was a bit confusing to read your nursing diagnosis. i would start out by writing each r/t item on it's own line first. do the same with the amb items. because you have so many words here, i would suggest using semi-colons to separate each of these items when you write them out in the diagnostic statement. i can't tell the difference between what is separate from other things because of all the commas. i believe you have jumbled up r/t and amb items. you need to be very clear in your diagnostic statement in classifying which is which. my understanding of qualifying related factors of nursing diagnoses with "secondary to" items is to use medical diagnoses. am i right about that? if so, then you do not need to qualify moisture as a related factor with a "secondary to" of an assessment item. to me, wearing briefs is part of the assessment data and not a medical diagnosis. rather than saying hyperglycemia as a related factor, i would use altered metabolic state.

    remember that your amb items support and relate back to the actual nursing diagnosis. what do an aka, bka and contractures have to do with skin integrity? they may contribute to the cause of the physical immobility, but they do not fit as symptoms, or defining characteristics (amb data), for this diagnosis. amb items would be things like description of actual skin breakdown or disruption that the patient has. the only thing you have listed that would qualify as an amb that i can see is "excoriation on sacrum/coccyx". as part of that description you should have taken some measurements of this excoriated area. if you have a nursing diagnosis book you need to look at the definition, defining characteristics and related factors for this specific nursing diagnosis to help you formulate this diagnostic statement.

    i could not find anything on impaired skin integrity at the gulanick or ackley care plan constructor websites. however, i did find something on impaired tissue integrity which is a very, very similar nursing diagnosis on the ackely site:
    http://www1.us.elsevierhealth.com/ev...ex.cfm?plan=49 - impaired tissue integrity

    this is what my copy of nursing diagnoses: definitions & classification 2005-2006 published by nanda international has to say about the nursing diagnosis, impaired skin integrity, on page 175:
    • "definition: altered epidermis and/or dermis.
    • defining characteristics [these would be your amb items]: invasion of body structures, destruction of skin layers (dermis), disruption of skin surface (epidermis)
    • related factors [these would be your r/t things]: external: hyperthermia or hypothermia, chemical substance, humidity, mechanical factors (e.g., shearing forces, pressure, restraint), physical immobilization, radiation, extremes in age, moisture, medications. internal: altered metabolic state, skeletal prominence, immunological deficit, developmental factors, altered sensation, altered nutritional state (e.g., obesity, emaciation), altered pigmentation, altered circulation, alterations in turgor (changes in elasticity), altered fluid status."
  2. by   isis73
    Skin integrity, impaired r/t physical immobility; altered circulation secondary to PVD; altered metabolic state secondary to DM; bowel incontinence and urinary incontinence AMB feeding tube, indwelling catheter and excoriation of sacrum/coccyx.

    Better? (Yes, I am getting confused between what is a r/t and what is AMB--and secondary to does refer to the medical diagnosis) Thanks!
    Isis73
  3. by   Daytonite
    the feeding tube and indwelling catheter are not listed in such a way as to show any contribution to the diagnosis. items following your "amb" need to be abnormal assessment data items that help to describe the nursing diagnosis. just listing "feeding tube" and "indwelling catheter" does nothing to help describe any impaired skin integrity. what was abnormal about the feeding tube or indwelling catheter that was leading to impaired skin integrity. was there redness or irritation around the feeding tube? if so, then you need to state that because that is something that helps define impaired skin integrity. how was the indwelling catheter contributing to impaired skin integrity? was the urinary meatus red and irritated? was the tubing taped to the skin so that the skin was breaking down from the tape? was the patient lying on the foley tubing and getting skin breakdown from that? if so, then that needs to be listed as your amb item, not just the catheter. is that making sense to you when i put it that way?

    to carry this further, when you continue onward to develop the nursing interventions for this nursing diagnosis, they will be aimed at the amb items in order to relieve and treat the impaired skin integrity. everything must follow a logical progression.

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