Pt had a stage IV decubitus ulcer..
Impaired tissue integrity R/T prolonged pressure as evidenced by 3.5 inch stage IV decubitus ulcer on patient's sacrum.
I am mainly concerned about the as evidenced part since I said "decubitus ulcer." Should I rephrase it or find something else as my s/s?
Thank you in advance for any advice.
(They call them "pressure ulcers" now, not decubitus.)
I'd say, Impaired tissue integrity, as evidenced by (sacral? heel? where?) pressure ulcer, related to (whatever of the following in the list below that applies)
Look at the list of approved related factors in the NANDA-I 2012-2014 (free 2-day shipping for students in Amazon) for the right terminology and pick any that apply in this case, not just "pressure" (there are probably more and you should include all that apply because they will all have to be addressed)
Here they are, because I'm feeling generous today Get the book.
Altered circulation, chemical irritants, deficient fluid volume, deficient knowledge, impaired physical mobility, mechanical factors (e.g., shear, pressure, friction), nutritional factors (e.g., deficit or excess), radiation or temperature extremes
Last edit by nurseprnRN on Feb 2, '13