Careplan question

Daytonite, BSN, RN · Mar 18, 2008

there is information on writing goal statements on post #157 of this thread: https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html. this is a direct link to it: https://allnurses.com/forums/2509305-post157.html

part of this is knowing how your nursing interventions are going to work. in the case of actual skin breakdown you would have to know the physiology of healing to know how many days it takes for a simple skin wound to heal in order to put a time frame on the healing. with redness (erythema) connected with pressure over bony prominences you need to find that same kind of information in a pathophysiology book.

however, i've got a problem with your long term goal here. first off, what is the "infection" the patient is at risk for here? your nursing interventions for this diagnosis should be to monitor for and prevent the signs and symptoms of this "infection", whatever it is. you really should have a clear impression of what infection this patient is at risk for. one of your nursing interventions should very clearly list the signs to look out (monitor the patient) for. then, your goals are the expected results of having performed those nursing interventions. goals and nursing interventions are intimately related.

so, i'm looking at your nursing diagnosis and long-term goal and wondering how a risk for an infection and maintaining skin integrity are related. the answer is they aren't. you've got a totally off the wall long-term goal that has nothing to do with the diagnosis. if you are trying to prevent skin breakdown, then use the nursing diagnosis risk for impaired skin integrity. contractures have to do with impaired physical mobility and, for the life of me, i do not see how they can be a risk factor of infection! did you verify that with a nanda reference? you need to go back re-think what your patient's risk is, diagnosis it correctly, develop the appropriate nursing interventions and then make goals that reflect the results you expect to occur when the nursing interventions are performed.

Cardigan2 · Mar 18, 2008

my thougnts on the 'risk for infection' were for respiratory infections, possible skin infection due to breakdown due to immobility.

my interventions will certainly incorporate care for preventing these types of infections. tcdb, reposition qh, etc...

i'm just looking for an appropriate timeframe. my thinking was that the time frame should be daily or every shift seeing that this pt. is totally immobile.

i am thinking that his contracture limits his mobility and due to the limited mobility..this person could end up with respiratory problems/infections.

the patient does not currently have an infection. i'm just trying to prevent one due to his immobility.

cardigan2

there is information on writing goal statements on post #157 of this thread: https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html. this is a direct link to it: https://allnurses.com/forums/2509305-post157.html
part of this is knowing how your nursing interventions are going to work. in the case of actual skin breakdown you would have to know the physiology of healing to know how many days it takes for a simple skin wound to heal in order to put a time frame on the healing. with redness (erythema) connected with pressure over bony prominences you need to find that same kind of information in a pathophysiology book.
however, i've got a problem with your long term goal here. first off, what is the "infection" the patient is at risk for here? your nursing interventions for this diagnosis should be to monitor for and prevent the signs and symptoms of this "infection", whatever it is. you really should have a clear impression of what infection this patient is at risk for. one of your nursing interventions should very clearly list the signs to look out (monitor the patient) for. then, your goals are the expected results of having performed those nursing interventions. goals and nursing interventions are intimately related.
so, i'm looking at your nursing diagnosis and long-term goal and wondering how a risk for an infection and maintaining skin integrity are related. the answer is they aren't. you've got a totally off the wall long-term goal that has nothing to do with the diagnosis. if you are trying to prevent skin breakdown, then use the nursing diagnosis risk for impaired skin integrity. contractures have to do with impaired physical mobility and, for the life of me, i do not see how they can be a risk factor of infection! did you verify that with a nanda reference? you need to go back re-think what your patient's risk is, diagnosis it correctly, develop the appropriate nursing interventions and then make goals that reflect the results you expect to occur when the nursing interventions are performed.

PsychNurseWannaBe, BSN, RN · Mar 18, 2008

My thougnts on the 'Risk for infection' were for respiratory infections, possible skin infection due to breakdown due to immobility.
My interventions will certainly incorporate care for preventing these types of infections. TCDB, reposition qh, etc...
I'm just looking for an appropriate timeframe. My thinking was that the time frame should be daily or every shift seeing that this pt. is totally immobile.
I am thinking that his contracture limits his mobility and due to the limited mobility..this person could end up with respiratory problems/infections.
The patient does not currently have an infection. I'm just trying to prevent one due to his immobility.
Cardigan2

Hi Cardigan2,

First...Risk for dx do not have AEB. You can't have an AEB when talking about a possibility of something happening because that something hasn't happened.

I understand what you are getting at with Risk for infection and the fact that she is immobile which increases the risk for respiratory decline and possible infection... but I don't think that dx really work here. By all means you could use a different dx and then one of your interventions could be to monitor for S/S of respiratory complications, such as infections.

Your dx started off about possiblity of infection.... you replied you were thinking about resp complications, but then talk about skin breakdown and such. It is kinda scattered all over.

My thougnts on the 'Risk for infection' were for respiratory infections, possible skin infection due to breakdown due to immobility.

With the above... the nurse should be intervening with the last part, immobility because as you mentioned, (going backwards) immobility -> skin breakdown -> infection. Why wait until the infection part? Tackle the first thing first in hopes that the others will not happen. With a dx of immobility you can still have to monitor for S/S of skin breakdown and S/S of infection.

But to answer your question, (LOL), q shift would be appropriate.

Daytonite, BSN, RN · Mar 18, 2008

nursing dx; risk for infection r/t immobility as evidenced by contractures

i was in a hurry to complete an answer to your post because i had to get to a doctor's appointment, but on the way to my appointment it dawned on me that i had missed an important point about your nursing diagnostic statement and that is that "risk for", or anticipatory problems, cannot have symptoms, or defining characteristics, like you have listed "contractures". why? for the very simple reason that these problems do not exist yet, so there is no way there can be any symptoms of the problem yet!

you need to totally restructure these anticipatory diagnoses that you are planning to use and re-write them so they make logical sense. you also need to look at the nanda risk factors for these diagnoses to get the underlying cause of the risk clearly and rationally established.

risk for infection r/t stasis of body fluids (reference: see nanda information of risk factors for this diagnosis here: [color=#3366ff]risk for infection). a satisfactory short term goal would be that patient will have clear lung fields (or other non-symptoms) daily. long term goal: no respiratory infection upon discharge or other length of time.

risk for impaired skin integrity r/t physical immobilization. short term goals can be things like a turning schedule will be developed and implemented within 24 hours. this, of course, would have a nursing intervention that clearly spelled this turning schedule out. what better long term goal than within one week patient's skin will be intact and without erythema over the following areas of concern: xxx? again, make sure you have the nursing interventions to specify these areas and the nursing preventative care.

do you have a care plan or nursing diagnosis book to help you out? i am concerned about your construction of the 3-part nursing diagnostic statement.

the 3-part nursing diagnosis statement has this structural format:

p - e - s

p

= problem

e

= etiology

s

= symptoms

or

problem - etiology(ies) - symptoms

these are, in nanda language

nursing diagnosis - related factor(s) - defining characteristic(s)

in a care plan they look like this:

problem [related to]etiology(ies)[as evidenced by]symptom(s)

or

nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)

the related factor is the underlying cause of the problem or the cause of the signs and symptoms that the patient is having. to help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. to help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". "by taking away this factor, will the symptoms go away?"

remember this important rule: you cannot list any medical diagnosis as a related factor. you have to state a medical condition in some other scientific terms. as an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". they essentially mean the same thing--the difference is in the phrasing of the words.

the defining characteristics are always the signs and symptoms that come from that list you created from your assessment activities. these will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.

Cardigan2 · Mar 19, 2008

Thank you...I understand exactly what you're saying.

I appreciate you taking the time to explain.

:)

Hi Cardigan2,
First...Risk for dx do not have AEB. You can't have an AEB when talking about a possibility of something happening because that something hasn't happened.
I understand what you are getting at with Risk for infection and the fact that she is immobile which increases the risk for respiratory decline and possible infection... but I don't think that dx really work here. By all means you could use a different dx and then one of your interventions could be to monitor for S/S of respiratory complications, such as infections.
Your dx started off about possiblity of infection.... you replied you were thinking about resp complications, but then talk about skin breakdown and such. It is kinda scattered all over.
With the above... the nurse should be intervening with the last part, immobility because as you mentioned, (going backwards) immobility -> skin breakdown -> infection. Why wait until the infection part? Tackle the first thing first in hopes that the others will not happen. With a dx of immobility you can still have to monitor for S/S of skin breakdown and S/S of infection.
But to answer your question, (LOL), q shift would be appropriate.

PsychNurseWannaBe, BSN, RN · Mar 19, 2008

You are more than welcome!!