NANDA nursing diagnosis for pressure ulcers

hypocaffeinemia, BSN, RN · Apr 24, 2009

Do you have a question about why #2 was the correct answer?

flightnurse2b, LPN · Apr 24, 2009

for this question, you should be able to eliminate both choices 3 and 4 immediately, because the patient is no longer eligible for the risk diagnosis--he already has a pressure sore. then, you should be able to eliminate answer choice 1 because turning and repositioning is your intervention to prevent skin breakdown. choice number two is the only correct answer for this question.

look at what information your question is giving you about the client already. this client has been assessed and found to have an existing pressure sore. so his diagnosis of impaired skin intergrity is correct. now, look at the statement to find out the evidence that you have to have made that diagnosis, impaired skin intergrity, related to pressure (which is what caused the ulcer), as evidenced by stage 1 pressure ulcer (found upon assessment).

does that help a little? i was kind of confused of what you were asking for?

POMD01 · Apr 24, 2009

for this question, you should be able to eliminate both choices 3 and 4 immediately, because the patient is no longer eligible for the risk diagnosis--he already has a pressure sore. then, you should be able to eliminate answer choice 1 because turning and repositioning is your intervention to prevent skin breakdown. choice number two is the only correct answer for this question.
look at what information your question is giving you about the client already. this client has been assessed and found to have an existing pressure sore. so his diagnosis of impaired skin intergrity is correct. now, look at the statement to find out the evidence that you have to have made that diagnosis, impaired skin intergrity, related to pressure (which is what caused the ulcer), as evidenced by stage 1 pressure ulcer (found upon assessment).
does that help a little? i was kind of confused of what you were asking for?

I'm sorry for confusing you,what I'm looking for is any book or website that has the same kind of question to practice

Daytonite, BSN, RN · Apr 25, 2009

i understand very well what you are asking because i wrote care plans for nursing homes and pressure ulcers are something that we care planned a lot for there. the information you need to diagnose pressure ulcers properly can be put onto half a page of a piece of paper and is found in the nanda taxonomy.

know how to assess and classify a stage i, ii, iii and iv ulcer (see http://www.nursingquality.org/ndnqipressureulcertraining/module1/default.aspx - pressure ulcer training tutorial). the tutorial will tell you what causes pressure ulcers
the choice of whether to use impaired skin integrity or impaired tissue integrity is based on the assessment of the patient's ulcer and it's cause (etiology). these two pages from nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig contain the nanda taxonomy and in the beginning of each nursing intervention section explains how the diagnostic choice is made based on the staging of the ulcer:
- impaired skin integrity
- impaired tissue integrity

[*]you also need to know how to put together a diagnostic statement correctly and know that the "related to", or related factor is the cause of the actual problem and the risk factor that will be the cause of anticipated problems. that information is in the front section of the ackley/ladwig book, but this is basically:

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem and resulting in the symptoms.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

[*]there are only a handful of causes for pressure ulcers (your example listed "effects of pressure" as a cause). i have discussed skin maceration before as a etiology of beginning skin breakdown on the student forums in the past: https://allnurses.com/general-nursing-student/i-feel-stupid-335307.html

[*]know the difference between an actual problem and a potential ("risk for") problem when diagnosing.

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a client was assessed to have a stage i pressure ulcer on his hip despite every 2hour turning and positioning. the nurse formulates which of the following as the appropriate nursing diagnosis for this client

impaired skin integrity related to frequent turning and positioning
impaired skin integrity related to the effects of pressure
high risk for impaired skin integrity related to redness
risk for pressure ulcer

impaired skin integrity related to frequent turning and positioning - frequent turning and positioning does not cause skin to break down

high risk for impaired skin integrity related to redness - this is an anticipated problem (hasn't happened yet). the stem of your question tells you the patient already has a stage i pressure ulcer on their hip, so this diagnosis would have been wrong. however, this diagnostic phrase is useless with any patient. redness does not adequately explain why a pressure ulcer would come about in someone who was being turned q2h.

risk for pressure ulcer - again, this is an anticipated problem (hasn't happened yet). the stem of your question tells you the patient already has a stage i pressure ulcer on their hip, so this diagnosis would have been wrong. this diagnostic phrase is missing its risk factor.