NCP Risk for impaired skin suggestions

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It's my first NCP from the ECF. I HAVE to use Risk for impaired skin integrity. My resident has Parkinson's, has intermittent bladder incontinence, and 80 years old. He can ambulate slightly by himself when not have an episode. I only spend a few hours with him for two days. His brief was dry the whole time and ate very well. The is documented at a 13 on the Bradins scale. I have a few questions regarding choosing my R/T, Noc, Nic.

First I came up with two different R/T:

1. R/T-Physical immobilization, moisture(bladder incontinence), extreme of age

2. rigidity, decreased range of motion, inability to turn self in bed 2* Parkinson's disease, increased shearing forces and pressure on sacrum 2* necessity of keepin HOB in semi-fowler's to avoid aspiration

I like the second one better, but he is able to readjust when he is not having an episode.

NOC:

1. Tissue integrity: Skin and mucous membranes

2. Immobility Cosequences Physiological

I like the second one also.

Nic:

1. Pressure Ulser prevention

2.Pressure managment

Now do my indicators have to be only related to my chosen NIC? I found some from each above NIC that I would like to use. I need at least 4 indicators. This is my weakest part, I believe. I need one more also and would like to hit on asses, assist(or care), teach, and manage. So far:

1. Pressure sores(maintain free from pressure sores)

2. Joint movement(maintain joint movement as much as possible)

3. Nutrition Status(maintain nutrition staus throught stay at facility)

This is my first NCP. It is difficult because I'm only with him for 3 days. I have not seen any indication of any impaired skin integrity. I want to use indicators that I can identify, keeping it simple. This is my first nursing course, so any suggestion would but extremely helpful. Thank you for your time, Brian

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Specializes in Adult Oncology.

assess skin integrity over bony prominences at every encounter

assist patient with repositioning every two hours

position patient using pillows to relieve pressure over bony prominences while maintaining semi fowlers position

consider use of air mattress to relieve pressure over bony prominences

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

with a "risk for" (anticipated) diagnosis your related factors are actually risk factors that will lead to the problem.

2. rigidity, decreased range of motion, inability to turn self in bed 2* parkinson's disease, increased shearing forces and pressure on sacrum 2* necessity of keepin hob in semi-fowler's to avoid aspiration


    • rigidity, decreased range of motion, inability to turn self in bed are ok as risk factors.
    • parkinson's disease can't be used in a diagnostic statement because it is a medical disease term
    • increased shearing forces and pressure on sacrum are ok to use as risk factors
    • necessity of keepin hob in semi-fowler's to avoid aspiration shouldn't be used. it is a treatment you are doing for another nursing problem and really has nothing to do with this diagnosis. even though the hob needs to be elevated the patient can still be turned.

i am not understanding the remainder of your question. are you concerned about the titles of the noc and nic outcomes and interventions you can use or just the actual outcomes and interventions. outcomes for anticipated problems are pretty much to prevent the problem from happening. interventions are limited to:

  • strategies to prevent the problem from happening in the first place
  • monitoring for the specific signs and symptoms of this problem
  • reporting any symptoms that do occur to the doctor or other concerned professional

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I am having trouble deciding the titles of the NIC and NOC. I have it narrowed down between these two. I think Pressure Ulcer Prevention is better for my NIC. Can I use activities that I found in the NIC book under another title(Pressure management). They still would help my patient. The other question is what NOC title to go with. I am hesitent to use Tissue Integrity: Skin and Mucous membrane because I don't believe any mucous membrane is at risk. But can I use some indicators(NOC) found under each title. The indicators that must be charted with measureable outcomes. I think I can come up with enough actions specific to my client to help him. I just need help picking the best NIC and NOC titles, and the best related to characteristics. I am also confused if it is accecptable to use measureable indicators found under NOC titles that I did not choose. I am sorry if I am confusing. I would like my first NCP to be good. Thank you all ffor the help, it means a lot to me, Brian

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