General question about nursing diagnosis

  1. 0
    I have written several care plans and I have noticed something in doing so: The NANDA approved nursing diagnosis and uses don't always fit the situation.

    I have the book: Nursing Diagnosis Handbook. Right now I am working on a diagnosis for "Impaired skin integrity." I am supposed to use the listed NOC and NIC.

    There are only three NOC outcomes listed in the book:

    Immobility consequences: Physiological
    Tissue Integrity: Skin and Mucous Membranes
    Wound Healing: Primary intention

    I have to list one NIC and NOC, then three goals, then three interventions for each goal.

    I know that the goals and interventions should be relevant to the NIC and NOC, however, that can be hard to do. Is it appropriate to blur the lines a bit? Can you list the NIC and NOC but also use goals and interventions that go with a different NIC and NOC?

    In the long run, the patient needs all of the interventions for all three NOC outcomes.

    Any thoughts?
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  3. 5 Comments so far...

  4. 0
    most students eventually notice that the sexy nanda-i diagnosis they want to use doesn't meet patient criteria. they get into that position because they chose the diagnosis first, and then tried to fit the patient into it. this is exactly backwards, and it makes me crazy that they don't learn better explanations from faculty.

    in the case you mention, you say you want to use the diagnosis of impaired skin integrity. fine. to have made this diagnosis for this patient, you must have assessed this patient's skin and noticed one or more of the defining characteristics in the nanda-i classification, right? i do not know whether the book(s) you reference give all of the defining characteristics-- probably not, because nanda-i is pretty selective about what publications are allowed to quote long bits of their work. i'd quote them for you but i am traveling and don't have my desk library with me. i strongly suggest that you get the actual nanda-i book, 2012-2014 is the current edition; it's not that expensive and you'll use it a lot.

    after that, there is a nifty book on linkages between nanda-i, nic, and noc which might help you get your thoughts together.

    interventions are not outcomes, of course, so that is something you can clarify for yourself.

    what do you have so far? what are your assessment data? what have you thought about for your diagnoses, your plan for interventions, and outcome measures?
  5. 0
    Thank you again, you are great to take so much time to help me.

    I actually ended up filling it in. This is what I have: I am just not sure that all of my goals and interventions fall under the NOC and NIC I am using.


    NURSING DIAGNOSIS STATEMENT _Priority 2__ of _2
    _ Impaired Skin Integrity related to immobility as evidenced by pressure ulcers on the sacrum and left buttock.

    NURSING
    Assessment focused on NSG DIAGNOSIS
    OUTCOMES

    INTERVENTIONS

    RATIONALES DOCUMENTATION
    EVALUATION
    Patient has two pressure ulcers. One is on the sacrum and one is on the left buttock.
    Sacrum: Red with grey debris, small amount of serosanguinous exudate. Tunneling is present, tunnel is approximately 4 cm. Wound measures 13 cm at widest point

    Buttock: Red with small amount of serous exudate, no tunneling. Wound measures 9 cm at widest point.
    NOC: Tissue Integrity

    S.T. Goals:

    1. Patient will not show signs of infection during my shift.

    2. Patient will remain dry and clean during my shift.

    L.T.

    Wounds will heal within 3 months.
    NIC: Wound Care

    Goal 1:
    1. Assess wound for signs of infection with each cleaning, or at least every 4 hours.

    2. Monitor vitals (especially fever) q4hours for signs of infection.

    3. Administer medication to the wound as prescribed.

    Goal 2:
    1. Assess for bowel movement q2hours.

    2. Clean patient immeadiately after bowel movement.

    LT Goal:
    1. Promote fluids. In this case, maintain IV fluids as prescribed because the patient is NPO.

    2. Promote nutrician, espeacially protien consumption. In this case, administer all tube feeding as prescribed because the patient is NPO.

    3. Repostition the patient q2hrs to keep pressure off the wounds.

    Goal 1:
    1. Frequent assessment allows action to be taken at the earliest indication of infection (Wilkenson & Ahern, 2009).

    2. Fever is one of the body’s defence mechanisms against infection (Berman & Snyder, 2012).

    3. Medication must be given on the prescribed schedule to promote effectiveness and remain at therepuetic level (Berman & Snyder, 2012).

    Goal 2
    1. Frequent assessment allows the nurse to be aware of the patient’s needs in a timely mannor (Wilkenson & Ahern, 2009).

    2. If the patient is not cleaned quickly after a bowel movement, then microbes from the feces can move into the wound causing infection. Additionally, the ph of the feces will irritate the skin (Berman & Snyder, 2012).


    LT Goal:
    1. Proper fluid balance is one component of optimal health which will allow the body to heal (Smeltzer, Bare, Hinkle, & Cheever, 2010)

    2. Proper nutriecian is vital to healing. The body needs protein to grow new cells and heal wounds (Smeltzer, Bare, Hinkle, & Cheever, 2010).

    3. Reduced pressure will allow for better blood flow and promote tissue healing (Berman & Snyder, 2012).
    Data:
    700 assessment: patient has two pressure ulcers. Sacral wound is class 4 with tunneling to a depth of 4cm, and wound is 13cm at widest point. Wound has serosanguinous exudate with red and grey debris.
    Buttock wound is class 2. It is 9 cm at the widest point. Small serous exudate, no tunneling.

    Action:
    Assessed wound, and assessed vitals. Patient not febrile at this time.

    Cleaned wound and applied medication and clean bandage.

    Checked IV fluids for correct flow rate.

    Monitored patient q2 hours for BM, fever, and vitals.

    Administered tube feeding as prescribed.

    Repositioned patient q2hrs.

    Response:
    Patient remained free of infection during my shift.

    His wounds have not shown signs of increased tissue damage.


    Signature:
    Melissa Gallant SRN
    Goal 1: met


    Goal 2. met


    LT Goal: in process
    Erikson/Maslow’s Hierarchy Level:

    Basic needs
    EVALUATION
  6. 0
    Quote from missing 1972
    Thank you again, you are great to take so much time to help me.

    I actually ended up filling it in. This is what I have: I am just not sure that all of my goals and interventions fall under the NOC and NIC I am using.


    NURSING DIAGNOSIS STATEMENT _Priority 2__ of _2
    _ Impaired Skin Integrity related to immobility as evidenced by pressure ulcers on the sacrum and left buttock.

    NURSING
    Assessment focused on NSG DIAGNOSIS
    OUTCOMES

    INTERVENTIONS

    RATIONALES DOCUMENTATION
    EVALUATION
    Patient has two pressure ulcers. One is on the sacrum and one is on the left buttock.
    Sacrum: Red with grey debris, small amount of serosanguinous exudate. Tunneling is present, tunnel is approximately 4 cm. Wound measures 13 cm at widest point

    Buttock: Red with small amount of serous exudate, no tunneling. Wound measures 9 cm at widest point.
    NOC: Tissue Integrity

    S.T. Goals:

    1. Patient will not show signs of infection during my shift.

    2. Patient will remain dry and clean during my shift.

    L.T.

    Wounds will heal within 3 months.
    NIC: Wound Care

    Goal 1:
    1. Assess wound for signs of infection with each cleaning, or at least every 4 hours.

    2. Monitor vitals (especially fever) q4hours for signs of infection.

    3. Administer medication to the wound as prescribed.

    Goal 2:
    1. Assess for bowel movement q2hours.

    2. Clean patient immediately after bowel movement.

    LT Goal:
    1. Promote fluids. In this case, maintain IV fluids as prescribed because the patient is NPO.

    2. Promote nutrition, especially protein consumption. In this case, administer all tube feeding as prescribed because the patient is NPO.

    3. Repostition the patient q2hrs to keep pressure off the wounds.
    Goal 1:
    1. Frequent assessment allows action to be taken at the earliest indication of infection (Wilkinson & Ahern, 2009).

    2. Fever is one of the body’s defence mechanisms against infection (Berman & Snyder, 2012).

    3. Medication must be given on the prescribed schedule to promote effectiveness and remain at therapeutic level (Berman & Snyder, 2012).

    Goal 2
    1. Frequent assessment allows the nurse to be aware of the patient’s needs in a timely manner (Wilkinson & Ahern, 2009).

    2. If the patient is not cleaned quickly after a bowel movement, then microbes from the feces can move into the wound causing infection. Additionally, the ph of the feces will irritate the skin (Berman & Snyder, 2012).


    LT Goal:
    1. Proper fluid balance is one component of optimal health which will allow the body to heal (Smeltzer, Bare, Hinkle, & Cheever, 2010)

    2. Proper nutrition is vital to healing. The body needs protein to grow new cells and heal wounds (Smeltzer, Bare, Hinkle, & Cheever, 2010).

    3. Reduced pressure will allow for better blood flow and promote tissue healing (Berman & Snyder, 2012).
    Data:
    700 assessment: patient has two pressure ulcers. Sacral wound is class 4 with tunneling to a depth of 4cm, and wound is 13cm at widest point. Wound has serosanguinous exudate with red and grey debris.
    Buttock wound is class 2. It is 9 cm at the widest point. Small serous exudate, no tunneling.

    Action:
    Assessed wound, and assessed vitals. Patient not febrile at this time.

    Cleaned wound and applied medication and clean bandage.

    Checked IV fluids for correct flow rate.

    Monitored patient q2 hours for BM, fever, and vitals.

    Administered tube feeding as prescribed.

    Repositioned patient q2hrs.

    Response:
    Patient remained free of infection during my shift.

    His wounds have not shown signs of increased tissue damage.


    Signature:
    Melissa Gallant SRN
    Goal 1: met


    Goal 2. met


    LT Goal: in process
    Erikson/Maslow’s Hierarchy Level:

    Basic needs
    EVALUATION


    I corrected several spelling errors...I think it fits. I use Ackley: Nursing Diagnosis Handbook, 9th Edition, which describes impaired skin integrity ........

    NANDA-I
    Definition: Altered epidermis and/or dermis

    Defining characteristics.
    Destruction of skin layers; disruption of skin surface; invasion of body structures

    Suggested NOC Outcomes
    Tissue Integrity: Skin and Mucous Membranes, Wound Healing: Primary Intention, Secondary Intention
    Example NOC Outcome with Indicators

    Tissue Integrity: Skin and Mucous Membranes will be intact as evidenced by the following indicators: Skin integrity/Skin lesions not present/Tissue perfusion/Skin temperature/Skin thickness (Rate the outcome and indicators of Tissue Integrity: Skin and Mucous Membranes: 1 severely compromised, 2 substantially compromised, 3 moderately compromised, 4 mildly compromised, 5 not compromised

    NIC
    Interventions (Nursing Interventions Classification)

    Suggested NIC Interventions
    Incision Site Care, Pain Management, Pressure Ulcer Care, Pressure Ulcer Prevention, Risk Identification, Skin Care: Topical Treatments, Skin Surveillance, Wound Care, Wound Irrigation

    Example NIC Activities Pressure Ulcer Care
    Monitor color of wound bed, temperature, edema, erythema, moisture, and appearance of surrounding skin; Note characteristics of any drainage

    Client OutcomesRegain integrity of skin surface
    Report any altered sensation or pain at site of skin impairment Demonstrate understanding of plan to heal skin and prevent re injury
    Describe measures to protect and heal the skin and to care for any skin lesion
    Last edit by Esme12 on Jun 19, '12
  7. 0
    If there is tunneling, it is tissue, not skin. Only stage 1 or 2 pressure ulcer is only epidermis and dermis. If there is any involvement of the subcutaneous layers, it is Impaired Tissue Integrity, not skin. NIC for that is wound care.

    Your rationales are based in tissue healing too. Maybe approach it from that angle and see if you get the results you seek.
    Last edit by KatePasa on Jun 19, '12 : Reason: spelling
  8. 0
    Our professors actually don't like us to use the already made NIC and NOC's. We have to use our own words and ideas and just cite the rationale of it from any of our many nursing texts so I like that a lot because its more realistic to me. Everyone is so individual how could you possibly just use the NANDA ones? Plus in my opinion this makes you really think a lot more.


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