Care Plan Help

[greenfaery]

I am a first year nursing student. Our last clinical assignment was to do a focused skin assessment on our patient and then write a care plan based on that. My problem is that my patient had no problems with her skin. She was discharged that morning and was very mobile, had very good hygiene, healthy skin, hair, and nails- no reason for risk of impaired skin integrity. I didn't know what to do for a diagnosis and plan. The only thing I can think of is that she did leave the hospital with slight bruising on each forearm from her IV's, but does that qualify for a care plan? My instructor was not happy with me this morning when I didn't have it completed. Any advice?

[CT Pixie, BSN, RN]

Although she had healty looking skin, nails and hair she was in the clinical setting (hospital I assume) for some reason. Whenever there is a break in health, there is always a chace for inpaired skin integrity. How is her diet, what was her dx? For example, if she were in the hospital for some sort of surgery, she is at risk for impaired skin integrity..the incision site, you also mention IV sites, which are breaks in the skin. If she was in for a GI problem, her nutritional intake might not be optimal which can lead to break down in skin integrity.

Does that help..or make sense at all?

[medicalma'am]

I am putting finishing touches on a care plan that is due in the morning also. This is our first and not for a grade.

I would use 'risk of infection' because of her IV site. Use the bruising for 'AEB'.

[Daytonite, BSN, RN]

but your patient did have a problem with her skin! when you are doing a care plan you are, in essence, problem solving. in the first step of problem solving (care planning) you perform an assessment. this involves reviewing the medical record and doing a physical examination of the patient. when you assess the skin you are looking at/for these things:

• that it is intact
  
• turgor (normal, poor, tight, shiny)
  
• temperature (dry, warm, hot, cool, cold, clammy, diaphoretic)
  
• color (normal, pale, flushed, cyanotic, mottled, jaundiced, ashen, or other)
  
• ecchymosis/hematomas/rashes and their description)
  
• incisions/skin ulcers
  
• drains (list type, site and describe drainage)
  
• iv site/type (peripheral, central--triple lumen, picc, hickman, or other)

anything that is not normal is abnormal, and therefore is considered a problem. your patient had slight bruising (ecchymosis) on each forearm from her iv's. that is an abnormal skin assessment item. that is a symptom that classifies the patient as having the nursing diagnosis of impaired skin integrity. there are interventions that are done for that!

so, now you have an unhappy instructor and your grade may suffer for it. if you can remedy this, do so. if not, do better next time. read the posts on these threads:

• https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
  
• https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)
  

[greenfaery]

Thank you that was really helpful! I will definately look into interventions for impaired skin integrity r/t peripheral IV's. Actually that is one of my problems, my nursing book covers a lot of assessment and critical thinking skills, but not a lot of practical interventions. Would a care plan book offer more interventions?

[greenfaery]

Also, is it safe to say that whenever someone has and IV (or any invasive device for that matter), I could always use the diagnosis

"risk for infection"?

[greenfaery]

I am putting finishing touches on a care plan that is due in the morning also. This is our first and not for a grade.

I would use 'risk of infection' because of her IV site. Use the bruising for 'AEB'.

medicalma'am,

I was told that we were not supposed to use AEB statements with Risks. If there really were characteristics to plug into the AEB part, then it would not longer be a risk but an actual problem. Just thought you might wanna know :)

Audrey

[Daytonite, BSN, RN]

Also, is it safe to say that whenever someone has and IV (or any invasive device for that matter), I could always use the diagnosis

"risk for infection"?

Yes. That or Risk for Injury. If you use Risk for Injury you need to look up the complications of that particular invasive device and model your nursing interventions appropriately.