Impaired skin integrity or risk for??

Bug Out, BSN · Sep 3, 2009

Granted his skin integrity is impaired from the Sx wound but I like to focus Nursing Dx on things I can fix or prevent or otherwise intervene in. Infection, pain, tissue breakdown etc.

Can you fix the Sx wound? Certainly you can prevent infection but that is another direction. The Sx wound is intentional, are you going to take measures to undo the Sx wound?

I would say risk for impaired skin integrity r/t strict bedrest.

Now he is at risk for his bottom breaking down from the bed rest, what as a Nurse are you going to do to prevent the breakdown? Going this route will allow you to come up with a ton of interventions and goals.

Maybe go for increased nutritional needs...he is going to need much more protein to keep his bottom together while healing from Sx.

Pain and discomfort would be another big one, not only is he going to be in pain from Sx but sitting in bed 24/7 is extremely uncomfortable too.

intensity_too · Sep 3, 2009

Granted his skin integrity is impaired from the Sx wound but I like to focus Nursing Dx on things I can fix or prevent or otherwise intervene in. Infection, pain, tissue breakdown etc.
Can you fix the Sx wound? Certainly you can prevent infection but that is another direction. The Sx wound is intentional, are you going to take measures to undo the Sx wound?
.

Thank you Bug Out! This was exactly what I was struggling with as far as going with the "risk for" or straight to the "impaired skin integrity". What you said makes total sense. Nursing diagnosis should focus on things I can fix or prevent! That'll certainly guide my thinking from here forward.

I also have the nursing diagnosis' of acute pain, risk for infection, and risk for constipation.

I also included ineffective tissue perfusion because we were given the information of overall pallor as well as a Hgb of 8.2 and a HCT of 29.6%

I used powerlessness because he states, "I don't know how I am going to make the house payments and take care of my wife."

Am I on the right track??

Bug Out, BSN · Sep 3, 2009

Thank you Bug Out! This was exactly what I was struggling with as far as going with the "risk for" or straight to the "impaired skin integrity". What you said makes total sense. Nursing diagnosis should focus on things I can fix or prevent! That'll certainly guide my thinking from here forward.
I also have the nursing diagnosis' of acute pain, risk for infection, and risk for constipation.
I also included ineffective tissue perfusion because we were given the information of overall pallor as well as a Hgb of 8.2 and a HCT of 29.6%
I used powerlessness because he states, "I don't know how I am going to make the house payments and take care of my wife."
Am I on the right track??

Pain is good but boring...I think I used pain in every single care plan I have ever made in school. Easy filler but not impressive. Its the easy meat. My advanced med surg prof hated when we would us pain...he said, "DAMN IT! That's a given! Show me you guys are thinking!" lol Never stopped me from using it as filler though lol.

Risk for infection is a good one.

Risk for constipation is a good one too...boring but often over looked.

Ineffective tissue perfusion is going to be a biggy.

Powerlessness is eh...I wouldn't say that statement demonstrates "powerlessness." Is he feeling powerless or more like he is having a role performance alteration?

You know what connects all of these together to make a master Dx? Teaching! Make sure to make teaching a priority. Teach your patient how to help you help him...or better yet....teach him how to help himself.

Teach him to change positions often. Even if he can't make a drastic position change...maybe he can make freq small changes in between your q1h or q2h position shifts. Teach him how to use his pain meds...break through meds, kickers etc. Teach him how to cope with pain without meds...find that threshold.

P.S. FOOD! LOTS AND LOTS OF FOOD! All this business is going to increase his nutritional requirements right? Healing requires protein. He is going to need fiber or something to keep his pooper moving too.

intensity_too · Sep 3, 2009

I'll give you the Powerlessness. There's a diagnosis there, but I'm just unsure of which one to use. The information we were given is:

John also expresses a great deal of concern and anxiety about his current situation. Because he works for a construction company, he will be unable to work for many months; furthermore, he cares for his wife who has MS. He states, "I don't know how I am going to make the house payment and take care of my wife."

Caregiver role strain?

Anxiety?

Ineffective role performance?

I'm just not sure where to go with this information.

Bug Out, BSN · Sep 3, 2009

i'll give you the powerlessness. there's a diagnosis there, but i'm just unsure of which one to use. the information we were given is:
john also expresses a great deal of concern and anxiety about his current situation. because he works for a construction company, he will be unable to work for many months; furthermore, he cares for his wife who has ms. he states, "i don't know how i am going to make the house payment and take care of my wife."
caregiver role strain?
anxiety?
ineffective role performance? (they make a pill for this now.)
i'm just not sure where to go with this information.

who says you have to pick just one? you have 3 distinct dx, granted they may have a singular resolution but that does not mean you cannot attack 1 problem from 3 different angles.

you can throw in self care deficit too since he won't be performing all of his adls without assistance.

you forgetting the single most important dx....energy field disturbance.

student005 · Sep 5, 2009

You might also consider "Impaired Physical Mobility" and "Risk for Peripheral Neurovascular Dysfunction"...

falastinia · Sep 5, 2009

Risk for infection is huge and also impaired tissue integrity, being that the patient is on strict bedrest a good nursing diagnosis would be impaired tissue integrity, you want to make sure that you are monitoring tissue to prevent bed ulcers, you can carefully readjust the patient to allow for better tissue perfusion and prevent breakdown. Risk for infection, you want to monitor the incision site to make sure that skin around the incision is not becoming warm and inflammed (early sign of infection) also check patient to make sure they are not running a fever, even if slight, this can be early indication of infection. hope this helps

Daytonite, BSN, RN · Sep 7, 2009

when you are doing a care plan it is like taking a snapshot of the patient except that instead of getting a picture you are determining their nursing problems. the care plan is then a determination of the person's nursing problems and strategies to do something about them. i've read one reply you've gotten in particular that says a nursing diagnosis should focus "on things i can fix or prevent or otherwise intervene in". that made me wonder what that nurse does about the things they can't prevent or do any interventions for? sweep them under the rug, look the other way and pretend that they don't exist? do i want that person as my nurse? rns are problem solver, folks. outcomes (the result of our interventions), whether we like it or not,

improve/remedy of the patient's condition/problem
stabilize the patient's condition/problem
support the deterioration of the patient's condition/problem

if the result of your initial assessment is the patient has evidence of open skin around the pins of the external fixation device then that is impaired skin integrity r/t presence of fixation pins. impaired skin integrity is defined as altered epidermis and/or dermis. otherwise, use risk for infection r/t pressure of pins on skin surface.

"risk for" means an anticipated problem and no evidence of the problem exists yet.