Nursing Dx for pressure ulcer

Nursing Students Student Assist

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This is my first care plan and I'm already stuck.

The patient I'm assigned is 77 and on bedrest. On the care plan it says "risk for pressure ulcer" but that is not a nanda dx. And the only related dx I found in book are:

-impaired skin integrity (which she doesn't have)

-risk for infection (no wounds)

-risk for ineffective health maintenance (only for long term care)

I would love if someone can please help me in finding a correct dx.

THANKS! :cat:

Specializes in ICU.

Have you read the definitions that come along with the diagnosis? She does have impaired skin integrity. Go back and read the definition :)

also, if there's interventions listed, I bet a lot would make sense for your patient. Look more into it!

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What NANDA I reference do you have? What does NANDA I say about this diagnosis?

Care plans are all about the patient and the patients problems. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

  1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. Evaluation (determine if goals/outcomes have been met)

Tell me your assessment...What does this patient need? Tell me about your patient

Thank you!

I have Nursing Diagnosis Handbook by Batty J. Ackley and Nursing Care Plans by Meg Gulanick.

I looked up Impaired skin integrity but I don't think it fits that because the description says destruction of skin layers, and invasion and pressure ulcers.

I also did a care plan on acute pain for her upper gi bleed and knee pain. And anxiety because when I talked to her and she had lots of worry about not being able to taking care of herself, what's going to happen and upcoming procedures.

She is also hypotensive, anemic and diabetic. I guess I don't know really what is most important. I thought it would be her pain and what she tells me.

She may not have impaired skin integrity, but is she at risk for it? Why? What factors put this patient at risk for it?

What else could that GI bleed lead to other than pain? edit: she's anemic... why?

Also, why isn't she at risk for infection?

IMO anyone in the hospital is at risk for infection, she's 77 and on bed rest. Wounds aren't the only thing that cause infection. :)

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you!

I have Nursing Diagnosis Handbook by Batty J. Ackley and Nursing Care Plans by Meg Gulanick.

I looked up Impaired skin integrity but I don't think it fits that because the description says destruction of skin layers, and invasion and pressure ulcers.

I also did a care plan on acute pain for her upper gi bleed and knee pain. And anxiety because when I talked to her and she had lots of worry about not being able to taking care of herself, what's going to happen and upcoming procedures.

She is also hypotensive, anemic and diabetic. I guess I don't know really what is most important. I thought it would be her pain and what she tells me.

If she is anemic and hypotensive could she be volume depleted? Are her sugars under control? Here are few I can think of with just the little you said.

Decreased Cardiac Output

Fear

Deficient Fluid Volume

Risk for unstable blood Glucose level

Anxiety

Powerlessness

Impaired individual Resilience

Risk for compromised Human Dignity

You are correct that there isn't "risk for pressure ulcer" in the NANDA-I 2012-2014 (which is the ONLY definitive nursing diagnosis reference, because NANDA-I is the organization that writes and validates them all). Get it at Amazon for $29 and free 2-day delivery, or $25 for instant delivery to your Kindle or iPad.

There is, however, on page 437, exactly what you seek. "Risk for impaired skin integrity," defined as "at risk for alteration in dermis and/or epidermis."

The risk factors, one of which must appear in your patient for you to make this diagnosis, includes both internal (like emaciation or obesity, impaired circulation or sensation, and others) and external (extremes of age, mechanical forces, moisture, immobilization, to name a few).

This is why you must must must have the real book. There are many "care planning handbooks" but they all rely on the NANDA-I, and NANDA-I doesn't give them all blanket permission to copy the entire work (for obvious reasons). Since it comes out in a new edition every three years (the last one was 2009-2011, the next will be 2015-2017) if your handbook is not copyrighted during the current edition, it may very well be out of date, and that's why this very real and validated nursing diagnosis ISN'T IN IT. Get NANDA-I 2012-2014 now.

And wait-- did you think wounds were the only thing that can give rise to infections? Hmmm. Think a little more about that.

Thanks, GrnTea for the clarification about Ackley et al. We were required as students to use Ackley, but after much reading I will be purchasing Nanda-1-2012-2014.

I would definitely use Risk for Impaired Skin Integrity. Impaired skin integrity implies that there is already alteration in skin integrity. However, bed rest and decreased mobility related to age and diagnosis would put her at risk. :)

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