Impaired skin integrity--help! Is my care plan correct?

[lj016]

Please pick apart my care plan! I've been struggling with care plans and my instructor for my second rotation LOVES to pick assignments apart.

Few things I want to specifically address..

1. My nursing diagnosis, I don't like my aeb..not sure how to improve it/word it.

2. Are my goals SMART? I wrote in my revisions explaining why they didn't need to be revised but am not 100% confident. Also I am not sure how my LT goal is realistic--or that I am not sure how to explain that it is realistic.

3. Is my 2nd nursing ordered too long? Did I do it right? And is my rational appropriate for the intervention.

4. I am again not sure about my 3rd nursing order.

5. Lastly, I need one more intervention and I feel as though I exhausted the list from Ackley for Impaired Skin Integrity..I have one half written up about implementing an incontinence management plan to prevent exposure to chemicals in urine that strip and erode the skin. Though I am not sure what to write as I feel my intervention to apply cream applies to incontinence management plan.

Please excuse how it is setup, couldn't figure out how to make it nice and neat.

I really appreciate any help!! Thanks in advance!

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[TD=colspan: 2]Cues (organized as Subjective or Objective):

Subjective:

It hurts when I sit too long”

My bottom itches and it's uncomfortable”

Objective:

Erythema, raised, swollen, papules[/TD]

[TD=colspan: 2]Complete Nursing Diagnosis

Impaired skin integrity r/t extremes in age and excessive moisture aeb erythematic yeast like rash to sacral spine bilaterally.[/TD]

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[TD=colspan: 2]Revisions:

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[TD=colspan: 2]Outcome Statements (Short and Long Term)

ST:

Client will describe three measures to protect the skin from moisture by 1200 on 4/15.

LT:

Client will not develop further signs of skin breakdown throughout duration of hospitalization by reducing erythema and reducing size of rash by 50% by 4/19.

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[TD=colspan: 2]Evaluation of Outcome Achievement

ST: Goal partially met. Patient described two out of three measures to protect his skin from moisture. He described that he needs to pat his skin dry after bathing rather than rubbing and that he should change wet/moist undergarments as soon as possible. He verbalized his understanding that he should not sit in wet underpants” because that is what caused irritation to his skin on his sacral spine. Patient became distracted and confused and could not name a third measure protect his skin from moisture.

LT:

Goal partially met. Patient's skin has no signs of worsening or advanced impairment. Patient's skin integrity has not been further compromised. Unable to determine if the size of the rash and erythema reduction due to limited time spent with patient. [/TD]

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[TD=colspan: 2]Revisions:

ST: Revision not needed. Goal is specific for client to describe three measures to protect skin from moisture. Goal is measurable, client will be able to describe the three measures to protect the skin from moisture. Goal is attainable, patient was taught techniques to keep skin dry

Goal is realistic, client is awake, alert, and oriented and ready to learn techniques to protect skin from moisture.

Goal is time-bound, client will describe the three measures to protect the skin from moisture by 1200 on 4/15.

LT: Revisions not needed. Goal is specific for client, in that the client will not develop further breakdown of skin with reduction of erythema and size of rash. Goal is measurable, the size of the rash and erythema will reduce by 50%.Goal is attainable, the rash will be able to reduce in size and erythema with the techniques of keeping the skin protected from moisture, with the application of prescribed topical cream, and with initial and recurrent skin assessments to use as a comparative baseline for future assessments. Goal is realistic, client……..

Goal is time-bound, client's rash will reduce by 50% by 4/19.[/TD]

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[TD][/TD]

[TD=colspan: 2]Nursing Interventions (minimum of 4 with rationale, individualized nursing orders, and patient response)[/TD]

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[TD]1[/TD]

[TD=colspan: 2]Assessment Intervention: Nurse will assess site of skin impairment.[/TD]

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[TD=colspan: 2]Rationale: Assessing the skin will provide a comparative baseline for future assessments to establish progression towards goal and help determine appropriate interventions to be implemented.[/TD]

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[TD=colspan: 2]N.O.: Nurse will assess sacral spine for integrity of skin on 4/15 during AM care and/or when patient requires incontinence care.[/TD]

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[TD=colspan: 2]Pt. Response/Evaluation: Patient was accepting to the assessment during AM care. Patient seemed to be aware of irritated area and complained of sacral area itching” and feeling uncomfortable”. Patient's sacral spine had a yeast like reddened rash bilaterally.[/TD]

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[TD]2[/TD]

[TD=colspan: 2]Teaching Intervention: Nurse will teach the patient techniques to keep skin clean and dry.[/TD]

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[TD=colspan: 2]Rationale: When moisture is trapped against the skin for a prolonged period, maceration occurs as the result of constant wetness. Keeping the skin clean and dry reduces the amount of bacteria on the skin and reduces moisture.[/TD]

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[TD=colspan: 2]N.O.: Nurse will teach skin care techniques to keep skin clean and dry by 0900 on 4/15 by changing moist or wet undergarments as soon as possible, using warm water when bathing, cleanse with mild soap when bathing, to completely rinse body/area of soap residue, to pat the skin dry and not to rub, to check under all skin folds where water can collect, to avoid powder due to possible cracking and irritation, and to change liens when wet or moist as soon as possible.[/TD]

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[TD=colspan: 2]Pt. Response/Evaluation: Patient was accepting to education. He understood that he should not sit in wet underpants” because that is what caused irritation to his skin on his sacral spine. Patient needed repeating of education, he seemed to understand that he needed specific care to his rash but seemed uncertain and confused.[/TD]

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[TD]3[/TD]

[TD=colspan: 2]Action Intervention: Implement a written treatment plan for topical treatment of the skin impairment site.[/TD]

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[TD=colspan: 2]Rationale: A written treatment plan ensures consistency in care and documentation.[/TD]

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[TD=colspan: 2]N.O.: Nurse will implement a written treatment plan for topical treatment of the sacral spine by applying prescribed Miconazole with barrier cream to sacral spine twice a day, once during AM and once two hours before end of shift.[/TD]

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[TD=colspan: 2]Pt. Response/Evaluation: I was unable to apply medicated topical cream, since I am not signed off for medications yet. The nurse was able to apply the cream for me. Patient was accepting to the application of the cream. Patient stated that it is itchy” and that it hurts” when he sits too long. Patient's rash was erythematous, raised/swollen with papules.[/TD]

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[windsurfer8, BSN, RN]

You need to talk to a real human about this. You could have someone who is not even a real nurse on here or god knows who telling you "yes it is great!" This is seriously the worst place to review homework.

[CaringGerinurse525]

I don't think this is the worst place to get help with homework. I asked questions on here about priority when I was still in school (I've been out for 2 years), and Esme was very helpful. The OP posted her thoughts and views and didn't ask anyone to write her care plan for her. She is just looking for feedback.

[lj016]

All I am looking for is for some feedback, hoping someone can let me know if I am headed in the right direction.

[nurseprnRN, BSN, RN]

More or less, and you might realize that though the last Ackley is a very popular book it is working on expired, outdated NANDA-I nursing diagnoses, so do yourself a favor and get the current NANDA-I 2015-2017. It has a WONDERFUL student FAQ section, new in this edition, that will help you a lot with questions like this. You can get it for instant download for your e-reader (Kindle, iPad) or in hard copy in a few days from Amazon.

Now, in terms of your actual patient, it doesn't sound like this individual is going to be able to take personal responsibility for keeping himself clean and dry, so your nursing interventions to do or delegate will have to reflect that, as will your goals. You can make a goal that he'll know what to do and when to do it, but then when you say he forgets and he keeps being incontinent, that's a big loud voice in your nursing GPS saying RECALCULATE ROUTE!!!

[lj016]

If I change my nursing diagnosis to Impaired skin integrity r/t extremes in age and incontinence aeb raised, swollen, erythematic, yeast like rash. Then add an intervention that implements an incontinence management plan, do you think then I could still keep what I have? Or still recalculate route?

[nurseprnRN, BSN, RN]

If I change my nursing diagnosis to Impaired skin integrity r/t extremes in age and incontinence aeb raised, swollen, erythematic, yeast like rash. Then add an intervention that implements an incontinence management plan, do you think then I could still keep what I have? Or still recalculate route?

That would be a major recalculated route :) That would indicate you're thinking like a nurse, to do for him what he cannot do for himself. For extra points, what famous nursing theorist says this is a great model for nursing? :anpom:

[windsurfer8, BSN, RN]

Feedback from WHOM. I am saying you are going to take feedback and USE it for possibly turning in a paper from someone who may or may not even 1. Be a nurse. 2. Have any clue what they are talking about.

[klone, MSN, RN]

Um, that's kind of one of the major reasons this site exists...to help nursing students succeed. Most of our members here enjoy helping out students, as long as they first show their own thought processes on the subject.

In short, I totally disagree with Windsurfer. That's the whole purpose of the "nursing student assistance" forum here, after all. It seems odd to be chastising students for using this forum for the reason it was intended.