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Help with evaluation portion of Care Plan

Hello all. I am having some diff. with my care plan. I already have my 2 priority diagnoses, interventions, rationales, completed. My problem is this.

Diagnosis: Impaired skin integrity related to surgical and medical procedures AEB 16 cm incision of lateral aspect of R hip and L AC PICC line placement.

Interventions:(this is the only interevention I am having trouble with)

1. Repsition pt q 2'

rationale: dec pressure over boney prominances and improve circulation.

Evaluation (pt's respone to the intervention NOT what you actually did)! This is my problem... What else could I put here other than what I actually did e.g. reposition patient q 2'? I am having major brain block:banghead: and any help would be greatly appreciated. Thanks!!

~Vanessa

Jolie, BSN

Specializes in Maternal - Child Health.

Think about the desired outcomes of your nursing interventions. What do you want to see?

No s/s of wound infection? Edges of incision well approximated? No s/s of infection at insertion site of PICC? No redness of skin at the bony prominences? No evidence of skin breakdown?

Use these questions to formulate your evaluation criteria.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt.

first of all, let me preface what i am going to tell you by saying that everything that is planned for within one diagnosis (problem) is all related. the signs and symptoms are evidence of the problem (nursing diagnosis) and your interventions are aimed at altering those signs and symptoms. you really would like to have them go away and disappear because without them, the problem disappears and is solved. it is all very logical. evaluation is really another form of assessment--it is just assessment done after interventions have been performed in order to see what their affect has been. did they achieve the goals you were hoping for?

so, let me take a look at your diagnosis and planning.

diagnosis: impaired skin integrity related to surgical and medical procedures aeb 16 cm incision of lateral aspect of r hip and l ac picc line placement.

the definition of
impaired
skin
integrity
is
altered epidermis or dermis.
(nanda). this is the upper layer of the skin. an incision goes deeper than the subcutaneous layer of the skin, so you should use the diagnosis of
impaired
tissue
integrity.
i don't think it is appropriate to include the picc line because it is going to remain in place for some time and you can't expect the puncture site to heal until after it is removed. so this diagnosis should be
impaired
tissue
integrity r/t surgical invasion aeb 16 cm incision on the lateral aspect of r hip
.

intervention: reposition patient q2h

interventions must alter the etiology of the problem or the evidence supporting the problem. i am asking myself, "how is repositioning the patient every 2 hours going to alter, or change, the surgical incision in any way?" the answer is it won't. it's a nice intervention for a surgical patient, but it doesn't fit with the etiology here.

you have a 16 cm incision that you want to assist in getting healed. how are you going to do that? how about things like always doing sterile dressing changes, since this wound is on the hip you want to keep the patient positioned
off that incision
, and you want to monitor the incision q8h for any signs and symptoms of infection or drainage.

rationale: decrease pressure over boney prominances and improve circulation.

decreasing pressure over bony prominences is for
avoiding decubitus
. you are trying to
promote healing of a surgical incision here
. keeping the patient positioned off the incision is common sense to the fact that healing can't occur if circulation is denied the area when pressure is applied. if you perform sterile dressing changes, the rationale is sterile principles. the rationale for monitoring for signs and symptoms of infection or drainage is that it is part of the nurses role of assessment.

evaluation: (pt's respone to the intervention not what you actually did)! this is my problem... what else could i put here other than what i actually did e.g. reposition patient q 2'?

first of all, repositioning the patient q2h is not going to get this incision healed. any evaluation of an intervention is going to assess whether it achieved its goal which is going to move the patient closer to resolving the problem (the impaired tissue integrity). in order for this problem to be resolved, the evidence has to disappear. in this case, the incision has to heal. so, if the incision is showing signs of healing then the interventions must be working. how was the evidence obtained? the incision was measured, wasn't it? didn't you also note that it was well-approximated, had staples or sutures and ___ drainage, swelling or not? your goals should be improved changes to that. eventually, the staples/sutures get removed. eventually, the drainage stops. eventually, the surface skin closes completely. these are all things that get noted in evaluations.

the difference between initial assessment and evaluations is that assessments state things in a
negative
way and evaluations state them in a
positive
way. it's a subtle language difference, but you are still working with the same old evidence.

-----------------------------------------

diagnosis

impaired
tissue
integrity r/t surgical invasion aeb 16 cm incision on the lateral aspect of r hip.

goal

the incision will be healed.

intervention

monitor incision q4h and note the presence of any redness, swelling or drainage and describe each.

rationale

early recognition of complications will prevent the development of a more serious situation.

evaluation

incision shows no redness, swelling or drainage.

Thanks for breaking it down - it makes sense to think about it as "assessment=negative and evaluation=positive". On some of these care plans the evaluation seems hard to come by - I'll start by going back to the initial assessment from now on!

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