Care Plan: Risk for impaired skin integrity
- 0Feb 28, '07 by xlxmegxlxI 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?
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- 2Mar 1, '07 by VickyRN Senior Moderatorwelcome 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
- 0Mar 1, '07 by xlxmegxlxThank you so much. I talked to my instructor and she said the same thing about the nutritional status. Because my client is immobile and has limited communication ability the second diagnosis: Client will demonstrate three behaviors/ techniques to prevent skin breakdown by end of student nurse shift on _________ wouldn't be applicable for her.
After talking to my instructor we came up with the diagnosis: Risk for impaired skin integrity r/t excessive exposure to moisture,chemical irritants and reduced blood flow to tissue resulting from prolonged pressure.
So I was thinking that since my first goal addressed the reduced blood flow part of my dx, my secoond goal should be related to perineal area remaining free from signs and symptoms of chemical irritants including reddness and skin break down. What do you think?
I wanted to use the Risk for aspiration dx, however we had a selected list of dx to choose from.
Luckily my instructor gave me a day extension to complete this. So anyfeed back on my second goal sometime today would be a huge help. Thank you so much for the feedback!
- 0Sep 27, '08 by JaxsCan someone help me figure out how to write the care plan. If I have tissue perfusion ineffective cerebral, what is the conceptor rules for the R/T and AEB? Do I change the order of the words to be Ineffective cerebral tissue perfusion related to what is the cause AEB what are the symptoms?
Thanks for the help
- 1Sep 28, '08 by DaytoniteQuote from jaxsthe rules for constructing a 3-part nursing diagnostic statement are as follows. . .can someone help me figure out how to write the care plan. if i have tissue perfusion ineffective cerebral, what is the conceptor rules for the r/t and aeb? do i change the order of the words to be ineffective cerebral tissue perfusion related to what is the cause aeb what are the symptoms?
thanks for the help
- p. stands for the problem. the problem is written as the nursing diagnosis. the words you use in writing the nursing diagnosis have already been determined for you by nanda-i, the north american nursing diagnosis association, international. you merely need to look them up in the most recent copy of one of their publications such as nanda-i nursing diagnoses: definitions & classification 2007-2008 or in any of the many currently printed nursing care plan or nursing diagnose reference books that are in publication containing this information. a nursing diagnosis is only a shortened label of the nursing problem which is more broadly defined and expressed in the definition contained in these references.
- e. stands for the etiology. an etiology is the origin of cause of this identified nursing problem (p). it cannot be stated as a medical diagnosis. in the nanda taxonomy you will find etiologies listed for many of the nursing diagnoses under the headings of "related factors". for physiological nursing problems (nursing diagnoses) you will need to know the pathophysiology of the disease process in order to determine the correct etiology, or related factor.
- s. stands for the symptoms. symptoms are the manifestations of the identified nursing problem (p). in the nanda taxonomy you will find symptoms listed for many of the nursing diagnoses under the headings of "defining characteristics". symptoms are proof that the problem exists. you will not have symptoms for "risk for" diagnoses because these are not actual problems, but anticipated problems. symptoms are determined by performing a thorough assessment of the patient and finding what is abnormal. symptoms are abnormal findings.
p related to e as evidenced by s
p r/t e aeb s
the nanda taxonomy contains all the nursing diagnoses, their definitions, related factors (etiologies) and defining characteristics (symptoms). it can be found in these places:
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free: