Help with care plan; medical diagnosis: skin tear?

[Kvallejo]

help please! i am writing a nursing care plan for my patient who has an open wound on her leg from a fall. although she has dementia, is a high-risk fall pt. and has hypertension my ci wants me to focus the care plan on her skin tear. i am trying to write a care plan based off of this an i know i can write that she is risk for infection r/t ....but i am not sure what the actual medical diagnosis should be. i have to write about the pathophysiology, etiology, clinical manifestations and treatment of the medical diagnosis but i am not sure that a skin tear is an actual medical diagnosis.

can someone please point me in the right direction?

thank you in advance!

[sweetee0607]

I know that when we do our nursing care plans that we can't have a medical diagnois because as nurses we aren't allowed to diagnois because it is not within our scope. Now we can use NANDA approved diagnois. Since your CI wants you to focus on the skin tear I would look to see what some of the actual medical diagnois' are. I would use something like Impaired skin integrity r/t altered nutrition, with this dx you know that poor nutrition can be a cause (etiology) of the skin tear. Another that may work is Impaired skin integrity r/t immobility. I hope this helps you to get the ball rolling. Good luck!!!