nursing DX help

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i don't know why this is so difficult for me to wrap my head around. i am having no problems getting the information, assessing the patient, and getting an idea of the nursing diagnosis label to work with. my issue is getting the information onto my careplan as it should be, particularly in regard to the 3 part nursing diagnosis.

example: 88yr old female pt with recent cva, hemiplegia, almost completely w/c bound. she is bladder (always)/ bowel (sometimes) incontinent. i am going with "impaired skin integrity" as she is in briefs all day and has reddened areas over her buttocks and gluteal folds as well as a reddened open area about 1cm in diameter on her labia majora.

this is what i don't get how to do, and here is what i have so far:

impairedskin integrity r/t immobility and weakness 2 ̊ hemiplegia aeb redness and tenderness

how crazy do i go with it? the hemiplegia was caused by the cva, so should that be in the statement? would it be 2 ̊ hemiplegia 2* cva? and i think my r/t part is off...maybe it should be r/t pressure, moisture, impaired circulation...oh i don't know!

logically i know that if you can't move much and are sitting in a humid brief all day your going to have some skin issues. i just don't get how to say it like a nurse, lol. thanks for the help !:heartbeat

I would try Impaired skin integrity r/t incontinence A.E.B. pt has reddened areas over her buttocks and gluteal folds.... idk hope that helps some :redbeathe

This brings up a good point that I have never really got an answer to.

1 ND that results in 2 (or more) different AEB's because of 2 different r/t's. So I'm not sure if you can have multiple r/t's or what.

The redness over the coccyx is r/t pressure and moisture from immobility. But the wound on the perineum is caused by moisture from incontinence not really the immobility.

If I was you I would probably keep it simple and and chose 1.

Impaired Skin Integ.

r/t unrelieved pressure from immobility and sensory deficit Secondary to Hemiplegia

AEB non-blanchable erythema over coccyx

of course you can have multiple causes for a problem. this lady's perineum is breaking down because of her incontinence and her immobility-- think about it: she can't move, she can't get off that, there are probably wrinkles in her brief or whatever else she has on that make for pressure areas, plus her perineum is always moist and loaded with bacteria so the skin gets macerated. thus, we have:

"impaired skin integ.

r/t incontinence, unrelieved pressure from immobility, and sensory deficit secondary to hemiplegia

aeb non-blanchable erythema over coccyx, reddened areas over her buttocks and gluteal folds, and reddened open area about 1cm in diameter on labia majora. "

doesn't that more completely describe your findings and rationales? of course it does. it's always better to show how much you know and can apply to patient care than to skate by just "keeping it simple," i.e., doing the bare minimum. you have actually done a good job of assessing the causes and effects of this lady's problem, and now you can more clearly say what you plan to do about it. that's nursing. good job.

Thanks so much! Sounds fancier than I would have thought to put it too :D.

Everyone keeps saying "One day this will just come to you". I think thats far in the future!

Thanks again :)

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