General question about nursing diagnosis

nurseprnRN, BSN, RN · Jun 19, 2012

most students eventually notice that the sexy nanda-i diagnosis they want to use doesn't meet patient criteria. they get into that position because they chose the diagnosis first, and then tried to fit the patient into it. this is exactly backwards, and it makes me crazy that they don't learn better explanations from faculty.

in the case you mention, you say you want to use the diagnosis of impaired skin integrity. fine. to have made this diagnosis for this patient, you must have assessed this patient's skin and noticed one or more of the defining characteristics in the nanda-i classification, right? i do not know whether the book(s) you reference give all of the defining characteristics-- probably not, because nanda-i is pretty selective about what publications are allowed to quote long bits of their work. i'd quote them for you but i am traveling and don't have my desk library with me. i strongly suggest that you get the actual nanda-i book, 2012-2014 is the current edition; it's not that expensive and you'll use it a lot.

after that, there is a nifty book on linkages between nanda-i, nic, and noc which might help you get your thoughts together.

interventions are not outcomes, of course, so that is something you can clarify for yourself.

what do you have so far? what are your assessment data? what have you thought about for your diagnoses, your plan for interventions, and outcome measures?

tinyRN72, BSN · Jun 19, 2012

Thank you again, you are great to take so much time to help me.

I actually ended up filling it in. This is what I have: I am just not sure that all of my goals and interventions fall under the NOC and NIC I am using.

NURSING DIAGNOSIS STATEMENT _Priority 2__ of _2_ Impaired Skin Integrity related to immobility as evidenced by pressure ulcers on the sacrum and left buttock.

[TABLE=width: 100%]

[TR]

[TD]NURSING

Assessment focused on NSG DIAGNOSIS

[/TD]

[TD]OUTCOMES

[/TD]

[TD]INTERVENTIONS

[/TD]

[TD]RATIONALES

[/TD]

[TD]DOCUMENTATION

[/TD]

[TD]EVALUATION[/TD]

[/TR]

[TR]

[TD]

Patient has two pressure ulcers. One is on the sacrum and one is on the left buttock.

Sacrum: Red with grey debris, small amount of serosanguinous exudate. Tunneling is present, tunnel is approximately 4 cm. Wound measures 13 cm at widest point

Buttock: Red with small amount of serous exudate, no tunneling. Wound measures 9 cm at widest point.

[/TD]

[TD]NOC: Tissue Integrity

S.T. Goals:

1. Patient will not show signs of infection during my shift.

2. Patient will remain dry and clean during my shift.

L.T.

Wounds will heal within 3 months.

[/TD]

[TD]NIC: Wound Care

Goal 1:

1. Assess wound for signs of infection with each cleaning, or at least every 4 hours.

2. Monitor vitals (especially fever) q4hours for signs of infection.

3. Administer medication to the wound as prescribed.

Goal 2:

1. Assess for bowel movement q2hours.

2. Clean patient immeadiately after bowel movement.

LT Goal:

1. Promote fluids. In this case, maintain IV fluids as prescribed because the patient is NPO.

2. Promote nutrician, espeacially protien consumption. In this case, administer all tube feeding as prescribed because the patient is NPO.

3. Repostition the patient q2hrs to keep pressure off the wounds.

[/TD]

[TD]

Goal 1:

1. Frequent assessment allows action to be taken at the earliest indication of infection (Wilkenson & Ahern, 2009).

2. Fever is one of the body’s defence mechanisms against infection (Berman & Snyder, 2012).

3. Medication must be given on the prescribed schedule to promote effectiveness and remain at therepuetic level (Berman & Snyder, 2012).

Goal 2

1. Frequent assessment allows the nurse to be aware of the patient’s needs in a timely mannor (Wilkenson & Ahern, 2009).

2. If the patient is not cleaned quickly after a bowel movement, then microbes from the feces can move into the wound causing infection. Additionally, the ph of the feces will irritate the skin (Berman & Snyder, 2012).

LT Goal:

1. Proper fluid balance is one component of optimal health which will allow the body to heal (Smeltzer, Bare, Hinkle, & Cheever, 2010)

2. Proper nutriecian is vital to healing. The body needs protein to grow new cells and heal wounds (Smeltzer, Bare, Hinkle, & Cheever, 2010).

3. Reduced pressure will allow for better blood flow and promote tissue healing (Berman & Snyder, 2012).

[/TD]

[TD]Data:

700 assessment: patient has two pressure ulcers. Sacral wound is class 4 with tunneling to a depth of 4cm, and wound is 13cm at widest point. Wound has serosanguinous exudate with red and grey debris.

Buttock wound is class 2. It is 9 cm at the widest point. Small serous exudate, no tunneling.

Action:

Assessed wound, and assessed vitals. Patient not febrile at this time.

Cleaned wound and applied medication and clean bandage.

Checked IV fluids for correct flow rate.

Monitored patient q2 hours for BM, fever, and vitals.

Administered tube feeding as prescribed.

Repositioned patient q2hrs.

Response:

Patient remained free of infection during my shift.

His wounds have not shown signs of increased tissue damage.

Signature:

Melissa Gallant SRN

[/TD]

[TD]

Goal 1: met

Goal 2. met

LT Goal: in process

[/TD]

[/TR]

[TR]

[TD]Erikson/Maslow’s Hierarchy Level:

Basic needs

[/TD]

[/TR]

[TR]

[TD]

[/TD]

[TD]

[/TD]

[TD]

[/TD]

[TD]

[/TD]

[TD]

[/TD]

[TD]EVALUATION

[/TD]

[/TR]

[/TABLE]

Esme12, ASN, BSN, RN · Jun 19, 2012

Thank you again, you are great to take so much time to help me.

I actually ended up filling it in. This is what I have: I am just not sure that all of my goals and interventions fall under the NOC and NIC I am using.

NURSING DIAGNOSIS STATEMENT _Priority 2__ of _2_ Impaired Skin Integrity related to immobility as evidenced by pressure ulcers on the sacrum and left buttock.
[TABLE=width: 100%]
[TR]
[TD]NURSING
Assessment focused on NSG DIAGNOSIS
[/TD]
[TD]OUTCOMES
[/TD]
[TD]INTERVENTIONS
[/TD]
[TD]RATIONALES
[/TD]
[TD]DOCUMENTATION
[/TD]
[TD]EVALUATION
[/TD]
[/TR]
[TR]
[TD]Patient has two pressure ulcers. One is on the sacrum and one is on the left buttock.
Sacrum: Red with grey debris, small amount of serosanguinous exudate. Tunneling is present, tunnel is approximately 4 cm. Wound measures 13 cm at widest point
Buttock: Red with small amount of serous exudate, no tunneling. Wound measures 9 cm at widest point.
[/TD]
[TD]NOC: Tissue Integrity
S.T. Goals:
1. Patient will not show signs of infection during my shift.
2. Patient will remain dry and clean during my shift.
L.T.
Wounds will heal within 3 months.
[/TD]
[TD]NIC: Wound Care
Goal 1:
1. Assess wound for signs of infection with each cleaning, or at least every 4 hours.
2. Monitor vitals (especially fever) q4hours for signs of infection.
3. Administer medication to the wound as prescribed.
Goal 2:
1. Assess for bowel movement q2hours.
2. Clean patient immediately after bowel movement.
LT Goal:
1. Promote fluids. In this case, maintain IV fluids as prescribed because the patient is NPO.
2. Promote nutrition, especially protein consumption. In this case, administer all tube feeding as prescribed because the patient is NPO.
3. Repostition the patient q2hrs to keep pressure off the wounds.
[/TD]
[TD]Goal 1:
1. Frequent assessment allows action to be taken at the earliest indication of infection (Wilkinson & Ahern, 2009).
2. Fever is one of the body’s defence mechanisms against infection (Berman & Snyder, 2012).
3. Medication must be given on the prescribed schedule to promote effectiveness and remain at therapeutic level (Berman & Snyder, 2012).
Goal 2
1. Frequent assessment allows the nurse to be aware of the patient’s needs in a timely manner (Wilkinson & Ahern, 2009).
2. If the patient is not cleaned quickly after a bowel movement, then microbes from the feces can move into the wound causing infection. Additionally, the ph of the feces will irritate the skin (Berman & Snyder, 2012).
LT Goal:
1. Proper fluid balance is one component of optimal health which will allow the body to heal (Smeltzer, Bare, Hinkle, & Cheever, 2010)
2. Proper nutrition is vital to healing. The body needs protein to grow new cells and heal wounds (Smeltzer, Bare, Hinkle, & Cheever, 2010).
3. Reduced pressure will allow for better blood flow and promote tissue healing (Berman & Snyder, 2012).
[/TD]
[TD]Data:
700 assessment: patient has two pressure ulcers. Sacral wound is class 4 with tunneling to a depth of 4cm, and wound is 13cm at widest point. Wound has serosanguinous exudate with red and grey debris.
Buttock wound is class 2. It is 9 cm at the widest point. Small serous exudate, no tunneling.
Action:
Assessed wound, and assessed vitals. Patient not febrile at this time.
Cleaned wound and applied medication and clean bandage.
Checked IV fluids for correct flow rate.
Monitored patient q2 hours for BM, fever, and vitals.
Administered tube feeding as prescribed.
Repositioned patient q2hrs.
Response:
Patient remained free of infection during my shift.
His wounds have not shown signs of increased tissue damage.
Signature:
Melissa Gallant SRN
[/TD]
[TD]Goal 1: met
Goal 2. met
LT Goal: in process
[/TD]
[/TR]
[TR]
[TD]Erikson/Maslow’s Hierarchy Level:
Basic needs
[/TD]
[/TR]
[TR]
[TD][/TD]
[TD][/TD]
[TD][/TD]
[TD][/TD]
[TD][/TD]
[TD]EVALUATION
[/TD]
[/TR]
[/TABLE]

I corrected several spelling errors...I think it fits. I use Ackley: Nursing Diagnosis Handbook, 9th Edition, which describes impaired skin integrity ........

NANDA-I

Definition: Altered epidermis and/or dermis

Defining characteristics.

Destruction of skin layers; disruption of skin surface; invasion of body structures

Suggested NOC Outcomes

Tissue Integrity: Skin and Mucous Membranes, Wound Healing: Primary Intention, Secondary Intention

Example NOC Outcome with Indicators

Tissue Integrity: Skin and Mucous Membranes will be intact as evidenced by the following indicators: Skin integrity/Skin lesions not present/Tissue perfusion/Skin temperature/Skin thickness (Rate the outcome and indicators of Tissue Integrity: Skin and Mucous Membranes: 1 severely compromised, 2 substantially compromised, 3 moderately compromised, 4 mildly compromised, 5 not compromised

NIC

Interventions (Nursing Interventions Classification)

Suggested NIC Interventions

Incision Site Care, Pain Management, Pressure Ulcer Care, Pressure Ulcer Prevention, Risk Identification, Skin Care: Topical Treatments, Skin Surveillance, Wound Care, Wound Irrigation

Example NIC Activities Pressure Ulcer Care

Monitor color of wound bed, temperature, edema, erythema, moisture, and appearance of surrounding skin; Note characteristics of any drainage

Client OutcomesRegain integrity of skin surface

Report any altered sensation or pain at site of skin impairment Demonstrate understanding of plan to heal skin and prevent re injury

Describe measures to protect and heal the skin and to care for any skin lesion

KatePasa · Jun 19, 2012

If there is tunneling, it is tissue, not skin. Only stage 1 or 2 pressure ulcer is only epidermis and dermis. If there is any involvement of the subcutaneous layers, it is Impaired Tissue Integrity, not skin. NIC for that is wound care.

Your rationales are based in tissue healing too. Maybe approach it from that angle and see if you get the results you seek.

OB-nurse2013, BSN, RN · Jun 20, 2012

Our professors actually don't like us to use the already made NIC and NOC's. We have to use our own words and ideas and just cite the rationale of it from any of our many nursing texts so I like that a lot because its more realistic to me. Everyone is so individual how could you possibly just use the NANDA ones? Plus in my opinion this makes you really think a lot more.