Is this an acceptable 3 part nursing diagnosis? Is this an acceptable 3 part nursing diagnosis? | allnurses

Is this an acceptable 3 part nursing diagnosis?

  1. 0 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.
  2. 7 Comments

  3. Visit  mssjez profile page
    0
    That seems fine to me. Maybe one of the nursing instructors here can give their input from a professor's standpoint.
  4. Visit  nurseprnRN profile page
    4
    Good start! (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
    Jill2Shay, dawniepoo, Esme12, and 1 other like this.
  5. Visit  JS85 profile page
    2
    Thank you so much! I will definitely look into getting that book. It will make life a whole lot easier.
    Jill2Shay and Esme12 like this.
  6. Visit  Esme12 profile page
    0
    GrnTea is right....there are certain tools/books imperative to doing care plans. A good care plan book is one of them.
  7. Visit  nurseprnRN profile page
    0
    Quote from JS85
    Thank you so much! I will definitely look into getting that book. It will make life a whole lot easier.
    What a smart student!
  8. Visit  livRN2012 profile page
    0
    Agree with the NANDA book! Super helpful!
  9. Visit  Jill2Shay profile page
    0
    Thanks for that! I'm writing my first care plan next week!

    That Amazon "buy with one click" can get a person in trouble. I'll have that book in my hot little hands by Friday!

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