kelly. . .a "risk for" diagnosis is not an actual patient problem, but an anticipated problem you think might occur. therefore, you will have risk factors
rather than related factors
(your r/t part of the diagnostic statement), but no symptoms (your aeb part of the diagnostic statement) because the problem doesn't actually exist
however, when you are putting these kinds of diagnoses together in a care plan, you must have a idea of what problem you are thinking the patient is at risk for and keep the potential symptoms of that problem in your mind because your nursing interventions for this kind of diagnosis are either going to observe and monitor for those signs and symptoms and/or take measures to prevent them from occurring, got it?
as always, use a nursing diagnosis reference to help you with the actual language in constructing your nursing diagnosis statement. nanda put the taxonomy together, so we don't have to spend hours agonizing over how to go about wording these things. so, check out the nursing diagnosis for impaired skin integrity
(weblink: [color=#3366ff]impaired skin integrity
) before you turn it into risk for impaired skin integrity.
the related factors will become your risk factors for your "risk for" diagnosis that you want to use. while i understand you want to use immobility, also look at the related factors under impaired skin integrity.
do you think any of those other related factors (which will now become your risk factors) could be the cause of of a skin integrity problem for this patient of yours? if so, add to to your r/t part of your nursing statement. remember that related factors are etiologies (causes) of the nursing problem.
your diagnosis could end up looking something like this:
- risk for impaired skin integrity r/t physical immobility (aeb reddened skin over bony prominences with skin still intact, skin does not blanche when pressure is applied to it). [there is an actual nanda diagnosis of impaired wheelchair mobility, but it's definition is "limitation of independent operation of wheelchair within environment." page 140, nanda-i nursing diagnoses: definitions & classification 2007-2008]
- the part that i have in orange is not actually written but you keep it in the back of your mind. your nursing diagnoses address these "potential" symptoms so your nursing interventions are going to look something like this:
- assess patient q shift for redness over bony prominences on elbows, hips, heels and coccyx
- turn q2h and avoid shearing force
- check for incontinence q2h and keep bed linens dry and free of wrinkles
- keep skin clean and dry
- provide passive rom qshift
- when in wheelchair assure protective seating to avoid pressure over coccyx while seated in w/c
- monitor meal and nutritional intake and assure patient is eating adequate protein each day
- report any break in skin integrity to the doctor
now, finish off this last care plan and have a great holiday.