Care Plan Help!! NC

ahinson07 · Mar 12, 2014

What about impaired skin integrity/risk for...

NightNurseRN13 · Mar 12, 2014

Well, first your Nursing Dx are not complete. It's failure to thrive r/t _________ (example: depression) AEB ______________.

And yes... impaired bed mobility is definitely a risk factor for skin breakdown so I think that is appropriate.

Where are your interventions? And how will you evaluate if goals have been met or not?

Kuriin, BSN, RN · Mar 12, 2014

IMHO, that is the wrong diagnosis for #2. ahinson sadly gave the answer. :\

NightNurseRN13 · Mar 13, 2014

I don't think it's a wrong Dx. Impaired skin integrity is def. one for this patient but so is impaired bed mobility. You could use either one with that goal.

Kuriin, BSN, RN · Mar 13, 2014

How does "intact skin" relate to "impaired mobility"? I know you can get impaired skin from impaired mobility...but, how can a goal of intact skin do anything for impaired mobility? A goal for that would be something like, "By end of shift, patient will be in chair longer than a two hours a day," (not saying that's realistic in this case, but, it's measurable and relevant to the diagnosis). I guess I might've just been taught differently when it comes to diagnoses, tho. ;p

NightNurseRN13 · Mar 13, 2014

One of the expected outcomes for impaired bed mobility is The patient will have no complications associated with impaired bed mobility, such as altered skin integrity, contractures, venous stasis, thrombus formation, depression, altered health maintenance and falls.

Interventions: assist patient in maintaining anatomically correct and functional body positioning to relieve pressure, thereby preventing skin breakdown.

While I agree that impaired skin integrity is the better dx. I'm just saying that impaired bed mobility is also appropriate.

Kuriin, BSN, RN · Mar 13, 2014

Gotchya. Thanks for further explaining. :-)

FrankieJLetchworth · Mar 13, 2014

I actually decided to go with impaired skin integrity before I looked at y'all's comments. Thanks so much for replying. And we don't have to put r/t or aeb. So I ended up with failure to thrive #1 and impaired skin integrity #2. And my goal is g-tube site will remain free from purulent drainage by 3/14. And for failure to thrive my goal is client will eat 75% of lunch on 3/14.

NightNurseRN13 · Mar 13, 2014

I'm not sure I like your goal for gtube site since she has had it since 2011. Purulent drainage would suggest infection and for a gtube that is established infection isn't really an issue unless it's not being taken care of and contents are allowed to leak out and sit on the skin for long periods of time. For impaired skin integrity(risk for), I would think her biggest problem is her immobility, poor nutrition, age, sheering forces, friction (with the turning). I would stay with what you had before... intervention to be turning q2hr, encouraging proper positioning with the outcome of no break in skin.

edit: Staying with your goal, but changing the dx. to skin integrity is what I mean.

Esme12, ASN, BSN, RN · Mar 13, 2014

I actually decided to go with impaired skin integrity before I looked at y'all's comments. Thanks so much for replying. And we don't have to put r/t or aeb. So I ended up with failure to thrive #1 and impaired skin integrity #2. And my goal is g-tube site will remain free from purulent drainage by 3/14. And for failure to thrive my goal is client will eat 75% of lunch on 3/14.

Welcome to AN! The largest online nursing community!

What semester are you? Is this a real patient? What care plan book do you use? Why do you not need to make a ND statement? Is this supposed to be based on NANDA I?

If your goal is about skin integrity....but you have signs of infection. That diagnosis isn't applicable for the G-tube.

I need some direction! I have to do a care plan for an 84 year old female who is bedridden, gets in a geri chair for a few hours a day, has a g-tube since 2011 for meds and feeding (if eats less than 50%) has alzheimers, didnt talk to me much, unable to move legs or right lower are, uses a lift to get her oob q2h turn, incontinent. Diagnoses in chart: Alzheimers, abnormal posture, failure to Thrive, altered mental status, malaise/fatigue, epilepsy, 9/12 fall, femur fx, 4/10 fall, forearm fx, 6/11 UTI. My current care plan now is 1.) Failure to Thrive--goal: client will eat 75% of lunch on 3/11/14. But thats not the one I need help with. My #2 nursing dx is Impaired Bed Mobility--goal: client will maintain intact skin around the sacral area by 3/11/14 at 1400. Is this goal have to do with impaired bed mobility? I've completed my care plan to turn in TOMORROW but now im second guessing

You gave a lot of descriptions of her medical condition and medical diagnosis...but no assessment of the patient.

Care plans are all about the assessment...of the patient. 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.

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.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

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)
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)
Planning
(write measurable goals/outcomes and nursing interventions)
Implementation
(initiate the care plan)
Evaluation
(determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Esme12, ASN, BSN, RN · Mar 13, 2014

I actually decided to go with impaired skin integrity before I looked at y'all's comments. Thanks so much for replying. And we don't have to put r/t or aeb. So I ended up with failure to thrive #1 and impaired skin integrity #2. And my goal is g-tube site will remain free from purulent drainage by 3/14. And for failure to thrive my goal is client will eat 75% of lunch on 3/14.

But what evidence do you have of impaired skin integrity? Does she have skin break down?

NANDA I describes Impaired skin intergrity: Destruction of skin layers; disruption of skin surface; invasion of body structures

Related Factors (r/t)

[h=5]External[/h]Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation

[h=5]Internal[/h] Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence

Purulent drainage at the G-tube site is infection not impaired skin integrity due to shearing forces.