Yes, another care plan question (sorry!)

KEL2BanRN · Nov 29, 2007

I know there are a lot of care plan threads out there but I'm having a hard time wading through them, so I'm hoping someone can give me sort of a quick answer to save my behind and help me get this last care plan finished. My question is, do all nursing diagnoses have to have a r/t AND AEB? My diagnosis is RISK FOR impaired skin integrity . . . if it's a risk, what's the evidence? I'm saying r/t immobility (for a wheelchair bound pt).
Can someone help?
Thanks SO much.
Kelly

Kelly, risk-for diagnoses do not have AEB, because if there were s/s, they wouldn't be at risk, they'd already have it. Make sense? So, if they don't show s/s, but are at risk for it, you just put at risk for XXX related to XXX. I hope this helps! :)

mcknis · Nov 29, 2007

Kelly, I am guessing that if this person w/c bound, then there are other problems with this pt such as decreased tissue perfusion, impaired tissue integrity, nutritional deficits, activity intolerance, impaired mobility, impaired circulation, etc.

I would try to go with an actual dx unless your instructor say s you have to have a risk for dx. For additional help and for any future CP questions go to the site below. Great place and does almost all of the work for you.

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/A-B.html

mcknis

PsychNurseWannaBe, BSN, RN · Nov 29, 2007

For the most part, when doing a Risk for nursing diagnosis, you will not use AEB because once there is evidence of something, it no longer is a Risk for, but an actual diagnosis.

So it is fine to use; Risk for impaired skin integrity r/t physical immobilization.

Should your patient demonstrate signs of impaired skin integrity, then drop the Risk for and add AEB.

ERRN92 · Nov 29, 2007

Been along time since I did care plans...but a pt can also be at risk for breakdown due to poor nutrition (poor intake), poor circulation (pvd, dm, ..), infectious processes,...? Im sure theres more but its the best i can do this early.

Daytonite, BSN, RN · Nov 29, 2007

kelly. . .a "risk for" diagnosis is not an actual patient problem, but an anticipated problem you think might occur. therefore, you will have risk factors rather than related factors (your r/t part of the diagnostic statement), but no symptoms (your aeb part of the diagnostic statement) because the problem doesn't actually exist.

however, when you are putting these kinds of diagnoses together in a care plan, you must have a idea of what problem you are thinking the patient is at risk for and keep the potential symptoms of that problem in your mind because your nursing interventions for this kind of diagnosis are either going to observe and monitor for those signs and symptoms and/or take measures to prevent them from occurring, got it?

as always, use a nursing diagnosis reference to help you with the actual language in constructing your nursing diagnosis statement. nanda put the taxonomy together, so we don't have to spend hours agonizing over how to go about wording these things. so, check out the nursing diagnosis for impaired skin integrity (weblink: [color=#3366ff]impaired skin integrity) before you turn it into risk for impaired skin integrity. the related factors will become your risk factors for your "risk for" diagnosis that you want to use. while i understand you want to use immobility, also look at the related factors under impaired skin integrity. do you think any of those other related factors (which will now become your risk factors) could be the cause of of a skin integrity problem for this patient of yours? if so, add to to your r/t part of your nursing statement. remember that related factors are etiologies (causes) of the nursing problem.

your diagnosis could end up looking something like this:

risk for impaired skin integrity r/t physical immobility (aeb reddened skin over bony prominences with skin still intact, skin does not blanche when pressure is applied to it). [there is an actual nanda diagnosis of impaired wheelchair mobility, but it's definition is "limitation of independent operation of wheelchair within environment." page 140, nanda-i nursing diagnoses: definitions & classification 2007-2008]
- the part that i have in orange is not actually written but you keep it in the back of your mind. your nursing diagnoses address these "potential" symptoms so your nursing interventions are going to look something like this:
  - assess patient q shift for redness over bony prominences on elbows, hips, heels and coccyx
  - turn q2h and avoid shearing force
  - check for incontinence q2h and keep bed linens dry and free of wrinkles
  - keep skin clean and dry
  - provide passive rom qshift
  - when in wheelchair assure protective seating to avoid pressure over coccyx while seated in w/c
  - monitor meal and nutritional intake and assure patient is eating adequate protein each day
  - report any break in skin integrity to the doctor

now, finish off this last care plan and have a great holiday.

krenee · Nov 29, 2007

Kelly, I am guessing that if this person w/c bound, then there are other problems with this pt such as decreased tissue perfusion, impaired tissue integrity, nutritional deficits, activity intolerance, impaired mobility, impaired circulation, etc.

Well, I have to come up with three diagnosis, and there really isn't much to go on - she's a resident in a nursing home, she sits in a wheelchair during the day but she CAN walk. Impaired mobility is a thought though. Her circulation seems fine, and I am already doing risk for nutritional deficit because she only eats half of her meals.

Anyway, I appreciate all the info. Thank you all who responded!

Kelly

Daytonite, BSN, RN · Nov 30, 2007

kelly. . .having worked in nursing homes over the years i can tell you that the nursing home has a written care plan in place for this patient. it's required by federal law. did you, by any chance, get an opportunity to look at it? if it's possible, you might want to try to go back to the nursing home and ask the don (director of nursing) if you can look at this patient's nursing care plan one last time to help you with yours.

these nursing homes really focus in on patient's adls, nutrition and mobility. this is a bit different from hospitals. nursing homes are more concerned with maintenance care. they are required by federal and state laws to monitor the patient's weight and skin condition. so, these assessments would have been somewhere in this patient's chart. most of these patients have very poor nutrition. they were at home eating junk food or microwaving easy, cheap food. many had limited access to getting to grocery stores or being able to cook. so, getting proper nutrition is usually a big problem one way or another for them when they are admitted. without the institutional setup of the nursing home, these patients would revert to their old ways. we used to find these patient with bags of candy and cookies hidden in their rooms. this is not uncommon among this group. has to do with diminished capacity to taste as they get older so food doesn't taste as good to them, but stuff like sweets do. sweets are easy and cheap to come by if they can get someone to get them for them.

diversion and leisure activities is another problem. many elderly sit at home watching tv and that is their only stimulus. when they get into a nursing home the state inspectors look very closely at how these nursing homes are involving their patients in activities. isolation leads to depression. so, psychosocial interaction can be one of your nursing diagnoses. that's two nursing diagnoses right there in addition to your patient's skin integrity and mobility problems.

did your patient have any pain associated with this immobility problem?