Help with care plan on impaired skin integrity and acute pain

[12learn]

Hi,

I am a first semester ADN nursing student. I need help on two care plans that I have been working on for my clinical class. Here is the situation: My client is a 70 yrs old female. She is diagnosis with Mulitple sclerosis, wheelchair bound, she has a right ankle ulcer wound meaureed 3.4cmx5.0cm and an ulcer wound on mid-tibia measured 0.6cmx0.8cm, no depth on both wounds, both wounds are covered with 40% yellow slough, I think there are stage 2. She is c/o pain rated as a 5 on a scale of 1 to 10, showed facial grimacing when touch.

The nursing diagnosis I pick are:

1. Acute pain r/t inflammation of ulceration wound sites AEB verbalize pain and demonstrate facial grimacing upon touch.

2. Impaired skin integrity r/t altered circulation secondary to MS AEB ulceration wounds.

Are these right? I am not sure if I have the right Etiology. Also, which is the higher priority? I am thinking pain, because that is the client's main concern, but than the skin integrity is also important too. I am just lost. I would really appreciate if someone could help me on this. Thanks in advance for your times.

[HouTxNurse832]

On your 1st diagnosis with the acute pain you should definitely state the number the pt rated the pain ("5 on a 10 point scale with 10 being most severe")...you have to be very specific (well at least in my program).

I'm not 100% sure, but I think that the impaired skin integrity should be the priority diagnosis b/c it is an open wound so puts patient at risk for infection and should could have further breakdown if not monitored properly. Other than that they look pretty good to me :)

[ElleBea]

I think they both look good and I would go ahead and use the Impaired Skin Integrity as the priority because there are a lot of things that can happen with an open wound so you would want that the be a priority above treating the pain. Also, if you needed other NANDAs a good one that can go along with the Impaired Skin Integrity would be Risk for Infection as the previous person had said. They both look good though!

[monkeesilly]

I agree that they are correct. In my program we also have to state what is the acceptable pain level for that person. Skin integrity is your priority because that is the reason she is having pain, and there are multiple wounds.

[sunrock]

Hi,

I am a first semester ADN nursing student. I need help on two care plans that I have been working on for my clinical class. Here is the situation: My client is a 70 yrs old female. She is diagnosis with Mulitple sclerosis, wheelchair bound, she has a right ankle ulcer wound meaureed 3.4cmx5.0cm and an ulcer wound on mid-tibia measured 0.6cmx0.8cm, no depth on both wounds, both wounds are covered with 40% yellow slough, I think there are stage 2. She is c/o pain rated as a 5 on a scale of 1 to 10, showed facial grimacing when touch.

The nursing diagnosis I pick are:

1. Acute pain r/t inflammation of ulceration wound sites AEB verbalize pain and demonstrate facial grimacing upon touch.

2. Impaired skin integrity r/t altered circulation secondary to MS AEB ulceration wounds.

Are these right? I am not sure if I have the right Etiology. Also, which is the higher priority? I am thinking pain, because that is the client's main concern, but than the skin integrity is also important too. I am just lost. I would really appreciate if someone could help me on this. Thanks in advance for your times.

Always use the ABC= airway, breathing and circulation, when choosing a priority DX

[RNTutor, BSN, RN]

Just thought I'd throw in my two cents, and say that I agree! I would also put skin integrity as the priority.

I think there is such an emphasis on pain being the 6th vital sign that it's easy to get confused and think it is most important. But as sunrock posted, go back to the basics using ABC when you're unsure. Another method I use is "If I was only going to do ONE thing today, what would it be..."

[12learn]

Thank you very much for all of your thoughts and your times.