i understand very well what you are asking because i wrote care plans
for nursing homes and pressure ulcers are something that we care planned a lot for there. the information you need to diagnose pressure ulcers properly can be put onto half a page of a piece of paper and is found in the nanda taxonomy.
- know how to assess and classify a stage i, ii, iii and iv ulcer (see http://www.nursingquality.org/ndnqip...1/default.aspx - pressure ulcer training tutorial). the tutorial will tell you what causes pressure ulcers
- the choice of whether to use impaired skin integrity or impaired tissue integrity is based on the assessment of the patient's ulcer and it's cause (etiology). these two pages from nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig contain the nanda taxonomy and in the beginning of each nursing intervention section explains how the diagnostic choice is made based on the staging of the ulcer:
- you also need to know how to put together a diagnostic statement correctly and know that the "related to", or related factor is the cause of the actual problem and the risk factor that will be the cause of anticipated problems. that information is in the front section of the ackley/ladwig book, but this is basically:
- problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
- etiology - also called the related factor by nanda, this is what is causing the problem and resulting in the symptoms.
- symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
- there are only a handful of causes for pressure ulcers (your example listed "effects of pressure" as a cause). i have discussed skin maceration before as a etiology of beginning skin breakdown on the student forums in the past: I feel stupid. Can anyone answer a question about a care plan?
- know the difference between an actual problem and a potential ("risk for") problem when diagnosing.
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a client was assessed to have a stage i pressure ulcer on his hip despite every 2hour turning and positioning. the nurse formulates which of the following as the appropriate nursing diagnosis for this client
impaired skin integrity related to frequent turning and positioning
- impaired skin integrity related to frequent turning and positioning
- impaired skin integrity related to the effects of pressure
- high risk for impaired skin integrity related to redness
- risk for pressure ulcer
- frequent turning and positioning does not cause skin to break down
high risk for impaired skin integrity related to redness -
this is an anticipated problem (hasn't happened yet). the stem of your question tells you the patient already has a stage i pressure ulcer on their hip, so this diagnosis would have been wrong. however, this diagnostic phrase is useless with any patient. redness
does not adequately explain why a pressure ulcer would come about in someone who was being turned q2h.
risk for pressure ulcer -
again, this is an anticipated problem (hasn't happened yet). the stem of your question tells you the patient already has a stage i pressure ulcer on their hip, so this diagnosis would have been wrong. this diagnostic phrase is missing its risk factor.