I have a pt w/ Parkinsons. She has dysphagia, high aspiration percaution, contractures and immobility. One of my diagnosis is Risk for impaired skin integrity. I wasn't sure if I should include all of these symptoms in the r/t section, or if I could only list one r/t. I want to make sure I state my diagnosis correctly.
I need to list 2 goals. My first goal is: Clients skin will remain intact throughout duration of residency. Is this ok, or should I use AEB in this goal.
For my second goal I wanted to address her nutritional status, something like: client will maintain adequate nutrition status, or client will remain free from signs of malnutrion AEB_.
Can you give me any advice?
Mar 1, '07
welcome to allnurses, xlxmegxlx
you really need to consult your clinical instructor as to his/her preferences, but my advice would be:
risk for impaired skin integrity r/t rigidity, decreased range of motion, bradykinesia, contractures, and inability to turn self in bed secondary to parkinson's disease and increased shearing forces and pressure on sacrum secondary to necessity of keeping client in semi-fowler's position to avoid aspiration
the goal is excellent. again, check with your clinical instructor as to preference for "aeb" in goal. if this is required, you can state:
client's skin will remain intact throughout duration of residency aeb absence of reddened/ blanched areas, no disruption of skin surface
for the second goal, you could state:
client will maintain adequate nutritional status throughout stay at facility aeb nutritional labs (albumin, total protein, h & h, na+, k+, ca++, mg++) within normal limits, no changes from baseline skin turgor, no weight loss, fluid balance
this goal would be more appropriate for the nursing diagnosis: risk for imbalance nutrition: less than body requirements (imho)
a more appropriate second goal for the nursing diagnosis 'risk for impaired skin integrity' would be:
client will demonstrate three behaviors/ techniques to prevent skin breakdown by end of student nurse shift on _________
(in terms of nursing diagnoses, the highest priority one for this client is:
risk for aspiration r/t lack of spontaneous swallowing, difficulty swallowing, drooling secondary to slowness of the tongue, mouth, and throat muscles)
hope this helps
and best wishes on your assignment.
Last edit by VickyRN on Mar 1, '07