Need help constructing interventions/rationales

[beachgurl_1988]

I am a nursing student and have to do a concept map for an unreal patient. My 'patient' has obesity as a medical diagnosis, and my nursing diagnosis is:

Risk for Impaired skin integrity related to immobility as evidenced by skin breakdown on back and thighs.

I have to have four interventions, with a rationale for each one. This is where I hit problems. ( guess I'm not cut out for this part... we haven't had much practice on concept mapping etc)

My first intervention and rationale is:

Intervention: Keep skin dry and clean. Rationale: Moisture leads to skin breakdown. By keeping the skin dry and clean you are reducing moisure and reducing the amount of bacteria on the skin that may cause an infection.

My second intervention and rationale is:

Intervention: Reposition the patient every 2 hours or as the patient requests. Rationale: by repositioning the patient is not kept in one place for too long. Repositioning aids in circulation of the blood and helps with condition of the skin.

And there is where I have hit the roadblock. I am hoping these are okay (please let me know if I should word them differently or not) and any help with any other interventions/and rationales would be great. I would like to put in one for getting the patient out of bed and mobile and also maybe something about nutrition, but m not sure how to put that in there...

[Jules A, MSN]

Hi,

Do you have a care plan book? Mine gave a variety of interventions/rationales with each diagnosis and we were supposed to take them right from the book. Don't reinvent the wheel is what one instructor said. Good luck!

[labcat01, BSN, RN]

I'm not sure how strict your professors are going to be on your care plan but mine were always very strict and wanted our interventions to be as SPECIFIC as possible (it should include an action and a time frame to accomplish the action). They also wanted us to use acronym ACT (assess, care teach) as the basis for our interventions.

For example, you might want to ASSESS the skin every shift, provide CARE (turn q 2 hours, keep skin dry, use a barrier cream), and TEACH the patient (skin care, nutrition for wound healing, etc). This might give you an idea of where to start. So if you have to provide four interventions, 1-2 can be assessments, 1-2 can be a caring action, and 1-2 can involve teaching.

Now if you have a good care plan book, like JulesA recommended, this will help you tremendously in forming the rationales for interventions.

I hope that helps a bit. I'm on my way out or I would go a little further into this for you. Good luck!

[mauxtav8r]

If you have any books (any subject) that have the Evolve logo on the spine, go to the Evolve website for additional resources. The have a concept map creator that may help you.

There are also many websites that offer help. . . be cautious with those. Find out what your instructor is looking for. Some of them are very specific.

I am a senior student, graduating in 3 weeks and an instructor told me something just the other day that made SO MUCH SENSE!! Ok, assuming you have gotten through the nursing diagnosis, using yours for example, Risk for impaired skin integrity, then just switch it around to the positive for your patient goal, promote skin integrity.

Your rationale #1 is great. Rationale #2 does not immediately focus on the problem to be solved ("you turn them every 2 hours so that they are not in one place too long"). Express the problem that would occur if you did not do your intervention, like you did so well in #1.

Your data is first, which tells you the nursing diagnosis (patient is bedridden could lead to both of your interventions). The problem in the nursing diagnosis, if expressed positively, gives you what you want to accomplish. The interventions are the specific steps you take to get there. The rationales answer the question "why do you do that?"

Some good care plan books will give the actual study that found out why it is good to reposition Q2 or whatever.

One more thing -- if the client already has evidence of skin breakdown, they are no longer a risk for diagnosis, they have the actual problem. Risk for diagnoses do not have an "as evidenced by."

Good luck.

[beachgurl_1988]

Okay. So I have been working all day, and this is what I have come up with:

Medical Diagnosis: Obesity

Nursing Diagnosis: Risk for Impaired skin integrity related to decreased mobility as evidenced by skin breakdown on back and thighs.

Intervention/ rationale:

• Intervention: Keep skin dry and clean. Rationale: Moisture leads to skin breakdown. By keeping the skin dry and clean you are reducing moisure and reducing the amount of bacteria on the skin that may cause an infection.
  
• Intervention: Reposition the patient every 2 hours or as the patient requests. Rationale: by repostitioning the patient is not kept in one place for too long, preventing sores related to pressure over the body. Repostioning aids in circulation of the blood and helps with condition of the skin.
  
• Intervention: Use cushioning devices such as a egg-crate mattress or fleece pad under the pt. Rationale: decreases pressure over bony prominances and skin irritation.

4 Intervention: Mobilize/ Ambulate pt to nurses station and back to room t.i.d. Rationale: mobilizing pt will increase circulation and help pt develop the muscles required to ambulate themselves.

[bosnanurse]

HI. I must admit that I would go after your plan right away and tell you to "fix it"if you think that your teacher looks for small things. There are 3 different possilble ways to look into nursing dxs. One is Complete Nursing dx: Skin integrity , Impaired (has the problem) r/t Obesity and as evidence by ( skin breakage as s/s). Second is Risk dx that has a possible problem " risk for impaired skin integrity r/t obesity but no s/s because it is not still there but there is a chance to break, and third is just for promoting something that is good already as mother- child bonding , postive life outlook etc where there is no risk nor there is a problem.I hope you can get my point:)) Other girls told you how to organize in other way.. Good luck.

[leslie :-D]

why are you using risk for the nsg dx, since she has actual breakdown on back, thighs?

wouldn't it be imp skin integrity?

leslie

[Daytonite, BSN, RN]

Since you also posted about this on the Nursing Student Assistance Forum, I posted an answer for you there: https://allnurses.com/forums/f205/err-hope-i-got-diagnosis-stuff-right-pls-help-315356.html

[Babs0512]

Risk for venous emboli R/T immobility

Risk for impaired respiratory status r/t immobility

Risk for circulatory problems r/t immobility

the list could go on and on. Obesity and immoblity = problems waiting to happen.