Is this an acceptable 3 part nursing diagnosis?

  1. 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.
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  2. 7 Comments

  3. by   mssjez
    That seems fine to me. Maybe one of the nursing instructors here can give their input from a professor's standpoint.
  4. by   nurseprnRN
    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
  5. by   JS85
    Thank you so much! I will definitely look into getting that book. It will make life a whole lot easier.
  6. by   Esme12
    GrnTea is right....there are certain tools/books imperative to doing care plans. A good care plan book is one of them.
  7. by   nurseprnRN
    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. by   livRN2012
    Agree with the NANDA book! Super helpful!
  9. by   Jill2Shay
    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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