Care plan goal help please :)

[Jill2Shay]

During my assessment today I found a new stage 1 pressure ulcer on my patient. (I did report this to the nurse and wound nurse). I'm writing my care plan and looking to see if my goal is acceptable. I'm in block 1, btw.

My Nanda statement is:

Impaired skin integrity r/t pressure AEB unblanchable errythema present over sacral area.

I was thinking of a short term goal of: Patient will not have worsening of current pressure ulcer stage.

She's in the old-old category, very frail, very underweight and on hospice, so I don't feel like a goal of 'regaining skin integrity' is realistic on my time line as she's very agitated and not alert and oriented enough to follow directions to stay in the turned position we put her in. She also doesn't eat much so her protein intake probably isn't very good, so healing may be an issue.

Wanted to add that I found an article HERE (about half way down) with some info about the focus of wound treatment for patients at the end of life with a citation to the original article.

"For patients with short life expectancy, inadequate nutrition, and poor tissue perfusion, treatment goals can shift from a primary focus on healing to patient comfort and prevention of complications, reducing pain, managing exudate and odor, and providing for optimal functional capacity (McDonald & Lesage, 2006)."

[MendedHeart]

Your related to should be the pathophysiology of the problem..so what exactly happen to cause this?

Also..is your goal measurable? How would you determine if the wound has worsened? Be specific.

Her malnutrition is a cause of this issue and well as a factor in healing

[nurseprnRN, BSN, RN]

I think you've done very well in assessing this and its likelihood of improvement. In many cases like this the best you can hope for is no worsening; in some, the best you can hope for is pain management and comfort as it gets worse no matter what you do. But you learned that by doing your lit search (good find). Perhaps a nonshear, low airloss mattress would give her some comfort no matter how she moves and lies.

Thank you for sharing this; perhaps other students will get the idea about your assessment process and research into the actual problem, rather than doing a cookie-cutter "Pressure Ulcer Care Plan." Real individualization based on comprehensive assessment like this is the hallmark of the thinking nurse. Congratulate your faculty for me.

:flwrhrts:

[Jill2Shay]

Awe! Thanks. I really struggle with the critical thinking part of nursing, so it's nice to hear :)

[Esme12, ASN, BSN, RN]

I agree with GrnTea...well done

[akulahawkRN, ADN, RN, EMT-P]

That's a great article find! You've found something that's very individualized to that specific patient with a goal that's actually measurable. In this case, you don't want it to get worse. It's early (Stage 1) so there's a good potential for improvement, but you certainly don't want for it to progress. That's measurable!

Off hand, I'd say you'd pretty much nailed it. Good job!