risk for impaired skin integrity | allnurses

risk for impaired skin integrity

  1. 1 We are starting clincial Monday (nsg101) and have to go in with a generic risk for impaired skin integrity.

    the outcomes I can think of are 1. maintain clean and intact skin 2. vital signs WNL (don't know if I really need that one on this) 3. client will id risk factors 4. client will demonstrate techniques to prevent skin breakdown 5. client will verbalize understanding of treatment 6. client will report any altered sensation or pain

    I've only got 12 interventions and I'm sure there should be more.

    I just feel like I'm missing something really simple on this. We'll be going to a LTC. Any advice would be appreciated.
  2. Visit  firewife1997 profile page

    About firewife1997

    Joined Mar '07; Posts: 4; Likes: 1.

    19 Comments so far...

  3. Visit  burn out profile page
    2
    some areas to consider when assessing for impaired skin interity are

    1. nutrition..if the patient is malnourished nothing you can do will prevent
    or heal impaired skin. Even those that can eat will need increased protein to promote wound healing.

    2. elimination..if the patient is incontinent either bowel or bladder will contribute to intact skin breaking down and infecting as well as preventing impaired skin from healing.

    3.Activity..is the patient bed ridden and can not turn themselves or can they reposition themselves?

    4. Education if the patient is coherent enough to understand,,,most nursing home patients have some degreee of dementia, in home health sitting however education of care giver is very important.

    5. Ongoing assessment of treatment to determine if wound tissue is healing properly and if treatment is effective.

    6.other disease process that may interfere with wound healing i.i. diabetes, or peripheral vascular disease
    Last edit by burn out on Mar 3, '07
    lilibete and billythekid like this.
  4. Visit  Achoo! profile page
    0
    What interventions do you have?
  5. Visit  firewife1997 profile page
    0
    my interventions are

    repostition client q2h
    maintain nutrition and hydration intake 2000 ml/day
    use lift sheets to move client in bed
    teach client causes of pressure ulcers
    encourage ambulation if able
    keep bedclothes dry and free of wrinkles
    keep skin dry and clean
    monitor sites of risk qshift and prn
    bathe client every other day
    if incontinent, check q2h and change/clean prn
    use pillows or pressure reducing devices
    avoid massaging red areas or bony prominence
  6. Visit  Achoo! profile page
    0
    Skin assessment q shift
    vitals q shift
    Teach pt s/s of infection ( be specific)
    Monitor labs q shift ( WBC for sure)
    If pt is not ambulatory, leg excercises regularly to increase circulation
    Remove invasive devices as soon as possible ( IV's or catheters)
    Staff will perform hand hygeine before each encounter
    Use standard precautions when in contact with body fluids
  7. Visit  Daytonite profile page
    1
    hi, firewife1997!

    here are two websites with information on outcomes and nursing interventions for impaired skin integrity:

    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=48
    [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_063.php

    welcome to allnurses!
    billythekid likes this.
  8. Visit  risperdal profile page
    0
    just a question here, exactly what does NANDA mean with "Altered epidermis and/or dermis" as the definition for Impaired Skin Integrity?

    does dry skin qualify as Impaired Skin Integrity, or does it fall under Risk for Impaired Skin Integrity?

    thanks
  9. Visit  Daytonite profile page
    1
    They mean that there has been a disruption, or break in the skin, from its normal anatomical unimpairedness that extends through the two top layers of the skin, the dermis and epidermis.

    I would use Risk for Injury (skin breaks) for dry skin because that is what a skin breakdown of dry skin would be, a traumatic injury to the tissues and you want to prevent the injury from happening.
    risperdal likes this.
  10. Visit  ktwlpn profile page
    0
    Quote from firewife1997
    I just feel like I'm missing something really simple on this. We'll be going to a LTC. Any advice would be appreciated.
    Don't forget staff education-very important in LTC.
  11. Visit  risperdal profile page
    0
    Quote from Daytonite
    They mean that there has been a disruption, or break in the skin, from its normal anatomical unimpairedness that extends through the two top layers of the skin, the dermis and epidermis.

    I would use Risk for Injury (skin breaks) for dry skin because that is what a skin breakdown of dry skin would be, a traumatic injury to the tissues and you want to prevent the injury from happening.
    i knew i was right...got into an argument with my review lecturer on this last week
  12. Visit  Daytonite profile page
    0
    Quote from risperdal
    i knew i was right...got into an argument with my review lecturer on this last week
    to help prove your point, it helps to show the written nanda taxonomy on this. the proof is in the nanda definitions of these two diagnoses. you could use a care plan book or nursing diagnosis reference book that has the nanda information, that will work. or, you can print out these pages that have the nanda information right below the diagnosis titles:
  13. Visit  GAstudentNurse profile page
    0
    Hello everyone. I'm new here. I hope to graduate in the summer, but have gone from making all A's in clinicals/school last semester to C's this semester. Any help would be appreciated!

    I have a two careplans due. Diagnoses: Diabetes, COPD, PVD. Am thinking of Fluid Volume Excess AEB 1+ pitting edema, SOB at rest and exertion, and altered labs (Hbg, Hct). I'm struggling with goals! They must be, "realistic" goals (2 days). The patient also has kidney disease. For second careplan, I'm thinking of, "Risk for Impaired Skin Integrity". Other abnormal labs: Albumin (which I know will support that NANDA, and not sure if the other abnormal labs would but they include, Glucose, BUN/Creatine, CBC-RBC, Hgb, Hct, RDW, Lymphs). Any advice would be greatly appreciated. My patient is elderly and is a resident in a nursing home and was admitted due to complications with Diabetes. I'm not sure if I should choose Impaired Physical Mobility for second careplan or not. She isn't really mobile (just to the bedside commode) at times, adult diapers otherwise. I'm just having trouble tonight. Just a little steering would be greatly appreciated!

    I have been visiting this site for months now..........enjoy reading and learning! Thanks in advance for those that may take the time to respond!

    Last thought........can you use a medication as AEB......such as Lasix for FVE? Or, is that an intervention?
  14. Visit  Daytonite profile page
    1
    Quote from gastudentnurse
    hello everyone. i'm new here. i hope to graduate in the summer, but have gone from making all a's in clinicals/school last semester to c's this semester. any help would be appreciated!

    i have a two careplans due. diagnoses: diabetes, copd, pvd. am thinking of fluid volume excess aeb 1+ pitting edema, sob at rest and exertion, and altered labs (hbg, hct). i'm struggling with goals! they must be, "realistic" goals (2 days). the patient also has kidney disease. for second careplan, i'm thinking of, "risk for impaired skin integrity". other abnormal labs: albumin (which i know will support that nanda, and not sure if the other abnormal labs would but they include, glucose, bun/creatine, cbc-rbc, hgb, hct, rdw, lymphs). any advice would be greatly appreciated. my patient is elderly and is a resident in a nursing home and was admitted due to complications with diabetes. i'm not sure if i should choose impaired physical mobility for second careplan or not. she isn't really mobile (just to the bedside commode) at times, adult diapers otherwise. i'm just having trouble tonight. just a little steering would be greatly appreciated!

    i have been visiting this site for months now..........enjoy reading and learning! thanks in advance for those that may take the time to respond!

    last thought........can you use a medication as aeb......such as lasix for fve? or, is that an intervention?
    i think some explanation about diagnosing needs to be done first. doctors and nurses are not the only professions that diagnose. the definition of diagnosis is the resulting decision or opinion after the process of examination or investigation of the facts. if your toilet won't flush you call a plumber (or the apartment maintenance guy if you live in an apartment) to come in and fix it. before the guy does anything he inspects the toilet to see for himself that it, indeed, does not flush. he might also take the lid off the tank and look around before he determines what the problem is, gets out any tools and starts tinkering around and fixing the problem. this inspection, in our profession, is called assessment. determining what a problem is, in our profession, is called diagnosing. getting out tools and starting to tinker around, in our profession, is initiating nursing interventions.

    we follow the nursing process which is a problem solving method when care planning. it has 5 distinct steps and if you follow them in the sequence they are meant to occur, rational/logical solutions result. i write about this all the time on this thread: help with care plans: http://allnurses.com/general-nursing...ns-286986.html.

    step 1 assessment - think of yourself as a detective. we are always on the lookout for data. the more the better. data is what helps us make our decisions about the patient's care. assessment consists of:
    • a health history (review of systems) - this patient has diabetes (admitted for complications of the diabetes), kidney disease, copd, pvd
    • performing a physical exam - 1+ pitting edema (where exactly?), sob at rest and exertion
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - is elderly and lives in a nursing home, is only mobile to a bedside commode (at times) otherwise wears adult diapers (do you mean that she is incontinent?)
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - only information given is that she has an abnormal albumin, glucose, bun, creatinine, cbc, rbcs, hbg, hct, rdw and lymphs. stating a lab is "abnormal" is not good enough. a lab is either elevated or decreased and that makes a big difference in what it means. you also need to look up information about diabetes, kidney disease, copd and pvd and see if the patient has any of the signs, symptoms and complications that the textbooks talk about. the lab test results you copied down should be compared with what the textbooks talk about. you should start to put together a picture of what is going on medically with this patient. you need that information in order to help in choosing nursing diagnoses.
    • reviewing the signs, symptoms and side effects of the medications they are taking - ???
    step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data
    • sob with exertion
    • sob at rest
    • 1+ pitting edema
    • only mobile to a bedside commode
    • incontinent?
    step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
    • activity intolerance r/t imbalance between oxygen supply and demand secondary to copd aeb sob with exertion [more evidence is needed including pulse rates and b/ps]
    • ineffective tissue perfusion, peripheral r/t interrupted vascular blood flow secondary to pvd aeb 1+ pitting edema
    • impaired physical mobility r/t activity intolerance aeb only able to transfer to a bedside commode with ___ assistant helping
    • risk for falls r/t age and presence of vascular disease in lower extremities
    -----------------------------------------------
    i'm struggling with goals! they must be, "realistic" goals (2 days).
    goals can be looked at as being what you predict will happen as a result of your nursing interventions. let me give you a common real world example of some goals that you can identify with.
    i have a messy kid. (problem) i tell him, "in one hour i want all your clothes picked up off the floor and put in the dirty clothes hamper in the bathroom." (short term goal) "by dinnertime i want your bed made, the floor swept and the dresser straightened up." (a longer term goal) "go up to your room and start cleaning it right now." (order/intervention). "i want you to get all the clothes picked up off the floor." (order/intervention) "put the dirty clothes in the hamper in the upstairs bathroom." (order/intervention) "put your shoes in the closet shoe organizer." (order/intervention) "get those books and games off the floor and stacked neatly on your desk." (order/intervention)
    what you are trying to accomplish with nursing goals and nursing interventions is no different. your stumbling block is that you may not be clear as to what the predicted happening is supposed to be. when you are new at nursing you need to just sit and think about what will happen when everything falls into place after all the interventions have been done correctly. sometimes goals are as simple as the reversal of the symptoms that created the problem in the first place. you must have clearly identified symptoms of the problem which you are applying solutions (interventions) upon and from that you will get goals (results). if any of these elements are not present then there will be difficulty in getting them to materialize.
    fluid volume excess aeb 1+ pitting edema, sob at rest and exertion, and altered labs (hbg, hct).
    the problem with using this diagnosis is that you identify no cause (etiology. related factor) so there is no rational reason for choosing it. several nursing diagnoses include edema and sob as symptoms. altered labs (hbg, hct) is vague. are the labs elevated or decreased? if decreased, the patient could be hemorrhaging which would be deficient fluid volume. you have to be specific with your evidence.
    risk for impaired skin integrity.
    nice thought--where's your evidence that there is a problem? you must always have evidence.
    i'm not sure if i should choose impaired physical mobility for second careplan or not.
    i addressed this above. your evidence regarding this needs to be a bit more specific.
    can you use a medication as aeb......such as lasix for fve? or, is that an intervention?
    aeb is always evidence of a problem, the problem being your nursing diagnosis. i cannot think of when the use of diuretics would be used as an aeb in nursing diagnostic statements because it is not evidence of a problem. a medication is a physician's treatment of a patient's symptom.

    we nurses help the doctors carry out their medical treatment orders as well as perform our own independent nursing interventions. in care plans you can have collaborative nursing interventions which means you are assisting the doctor in carrying out his medical plan of care and say, "administer diuretics as ordered by the physician." i've used it as a risk factor for a diagnosis of risk for incontinence because it was an underlying cause for potential incontinence.
    GAstudentNurse likes this.


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