Quote from cardigan2
nursing dx; risk for infection r/t immobility as evidenced by contractures
i was in a hurry to complete an answer to your post because i had to get to a doctor's appointment, but on the way to my appointment it dawned on me that i had missed an important point about your nursing diagnostic statement and that is that "risk for", or anticipatory problems, cannot have symptoms, or defining characteristics, like you have listed "contractures". why? for the very simple reason that these problems do not exist yet, so there is no way there can be any symptoms of the problem yet!
you need to totally restructure these anticipatory diagnoses that you are planning to use and re-write them so they make logical sense. you also need to look at the nanda risk factors for these diagnoses to get the underlying cause of the risk clearly and rationally established.
risk for infection r/t stasis of body fluids
(reference: see nanda information of risk factors for this diagnosis here: [color=#3366ff]risk for infection
). a satisfactory short term goal would be that patient will have clear lung fields (or other non-symptoms) daily. long term goal: no respiratory infection upon discharge or other length of time.
risk for impaired skin integrity r/t physical immobilization
. short term goals can be things like a turning schedule will be developed and implemented within 24 hours. this, of course, would have a nursing intervention that clearly spelled this turning schedule out. what better long term goal than within one week patient's skin will be intact and without erythema over the following areas of concern: xxx? again, make sure you have the nursing interventions to specify these areas and the nursing preventative care.
do you have a care plan or nursing diagnosis book to help you out? i am concerned about your construction of the 3-part nursing diagnostic statement.
the 3-part nursing diagnosis statement has this structural format:
p - e - s
s = symptoms
problem - etiology(ies) - symptoms
these are, in nanda language
nursing diagnosis - related factor(s) - defining characteristic(s)
in a care plan they look like this:
problem [related to]etiology(ies)[as evidenced by]symptom(s)
nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)
the related factor
is the underlying cause of the problem or the cause of the signs and symptoms that the patient is having. to help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. to help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". "by taking away this factor, will the symptoms go away?"
remember this important rule: you cannot list any medical diagnosis as a related factor
. you have to state a medical condition in some other scientific terms. as an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". they essentially mean the same thing--the difference is in the phrasing of the words.
the defining characteristics
are always the signs and symptoms that come from that list you created from your assessment activities. these will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.