I'm I getting this right

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:D Hello, I'm in my second month of Nursing school and I love it! I'm learning so much. However, I'm having a hard time with care plans :eek:. Yes we have went over them briefly and our instructors told us to go home and make up our own care plans and I seem to get the pain diagnosis all screwed up! For instance a made up a Care Plan for a patient with a stage 1 pressure ulcer, and the patient complains of pain. Okay, I can come up with about 3 or 4 care plans out of that situation, but when it comes down to pain. Ugghh just terrible. Okay I my ND is "Pain acute related to stage 1 pressure ulcer as evidence by patient states 7/10 pain." Okay maybe I'm just hard on myself and I just think that is terrible. :crying2:
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the nursing dx is fine, but your related to cannot be a medical dx, which a pressure ulcer is... you could use skin breakdown, tissue damage... as long as it is not a medical diagnosis, but you can then add secondary to pressure ulcer AEB stating pain is 7/10 :)

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Okay thank you! those Med diagnosis is what is kicking my booty .... They are a pain!

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i know, but it will all fall into place... pretty soon they will just be coming to you when you look at some information lol!! I would also suggest a care plan book, they are really helpful! I can give you the names of the two that I have if you are not sure, and another thing is read posts on here about care plans and dx, they will really help increase your knowledge about how things are connected and looking at different aspects of the pt :)

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Specializes in Emergency Nursing.

Um, why not Impaired Skin Integrity? You can address the pain issue until the cows come home, but unless you address the impaired skin integrity the pain is always going to be there.

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I had trouble with the whole care plan/nursing diagnosis thing too, but I somehow managed to past that test with an 80%, even though I was confused. The teacher said we don't have to memorize the Tabler's chart of nursing diagnoses words...but it's confusing to me that we could know what to say if we don't memorize it! I mean I know about PIE and all that, but something about it still isn't clicking for me. Maybe I'm reading too much into it.

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Um, why not Impaired Skin Integrity? You can address the pain issue until the cows come home, but unless you address the impaired skin integrity the pain is always going to be there.

GREAT POINT!! this is a priority also, even though in stage 1 there is NO broken skin as of YET, pressure ulcers do tend to accelerate quickly if there is no intervention, if you do nothing for it right now it will just get worse, RISK for impaired skin integrity is a good one, your interventions will be to prevent any breakdown of the skin (air matress, T&P, skin care... you know the drill lol) but this is a great point on a risk for dx!

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well i addressed the pain, as priority, due to the fact that the patient was complaining of pain. so, reviewing "maslow's hierarchy of needs", the patient's need to reduce his or her pain is prevalent over anything else at that due moment. yea keeping skin intact is my main priority but i feel as nurses we're here to provide safety as well as comfort. you know having empathy.
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yes, pain management can be key -but you have to make sure that the pts nutrition/hydration are correct. also depending upon where the PU is, position, lack or irritants (such as urine or feces) have to be minimized which are easy nursing diagnosis/plans of action to put into your care plan.

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