Nursing dx: +MRSA wound; pressure ulcer

APBT mom, LPN, RN · Jan 17, 2008

Hello everyone,
I hope someone could help me on the wording on one of my nursing care plans.
My patient is a renal patient whose AV access site in his arm was + for MRSA. He also has a stage I pressure ulcer on his buttocks.
The diagnoses I am going to use is impaired tissue integrity and impaired skin integrity.
I'm having an issue with the r/t and the d/t parts.
For the MRSA infection: impaired tissue integrity R/T ______ D/T positive MRSA infection. Would the R/T be considered a mechanical factor because of the shunt?
For the Stage I pressure ulcer: Impaired skin integrity R/T impaired physical mobility D/T Stage one pressure ulcer OR Diabetes mellitus? I diagnosed the patient; it is not a medical diagnosis. The skin was intact and non-blanching erythemic. It was hot to the touch.
The medical diagnoses were ESRD, anemia, DM II, HTN, + MRSA in right forearm AV shunt, bilateral BKA.
Thanks so much,
Dani

The only way that I can think of wording it by using the diagnosis you have is

MRSA- impaired tissue integrity related to infection of AV shunt in right forearm as evidenced by pt being cultured for MRSA at shunt site and coming back positive.

Ulcer- impaired skin integrity related to pt being bed bound from bilateral BKA as evidenced by a non-blanching erythemous area that's hot to touch on the buttocks.

:brnfrt: :sleep:

It's late/early so that's the best I could come up with.

Daytonite, BSN, RN · Jan 17, 2008

infected shunts are considered a mechanical factor if you are coding them in the medical records office in preparation for billing. but, you are in the clinical area treating this problem and so we look at it a different way. to use impaired tissue integrity with relation to an mrsa infection involved with an av access site there needs to have been actual damage or destruction to the subcutaneous tissues around the site of the shunt to support the use of this diagnosis. then, the underlying pathophysiology of the tissue destruction is not directly due to the mrsa but the inflammation process (chemical irritants [the toxins produced by the mrsa and build up of pus], fluid excess [the resulting edema due to the inflammation in the area]) so that i would be wording the nursing diagnosis to read: impaired tissue integrity r/t chemical irritants and local fluid excess and swelling secondary to the inflammatory response produced by an mrsa infection aeb [your descriptors of the appearance of the shunt wound]. this thread has the detailed pathophysiology of the inflammatory response: https://allnurses.com/forums/f50/histamine-effect-244836.html (see post #3). the inflammatory response occurs first before the infection takes hold. what you are seeing in the shunt wound is the result of the inflammatory response of the body trying to localize and clear the infection out.

for a stage i pressure ulcer impaired skin integrity is the appropriate diagnosis to use. your related factor is always the underlying cause of what is responsible for the "altered epidermis and/or dermis". while physical immobility is a defining characteristic of this diagnosis and you can use it, is that the only reason? i was also thinking of pressure (r/t physical immobility and pressure). also, to say that diabetes is part of the cause you have to be able to relate the pathophysiology of the diabetes directly to the pressure ulcer and you really can't do that, i don't think, with what you already have. the diabetes contributes by causing a circulation and perfusion problem that sets up the roadway for pressure and immobility to do their damage. i would reword your diagnosis to say impaired skin integrity r/t impaired metabolic state, impaired circulation, impaired physical mobility and pressure due to diabetes mellitus aeb [your descriptors of poor circulation, elevated blood sugars, and description of the wound]. if your information from his chart shows his blood sugars to be out of whack periodically, you can also use impaired metabolic state as a related factor, but you'll need to include some of those elevated blood sugars in your aeb items. get some descriptors of impaired circulation to his skin in the defining characteristics (symptoms) such as pallor and poor capillary refill. i'm sure he also has poor peripheral pulses as well since he's already had one leg chopped off (look at the list of defining characteristics for the peripheral ineffective tissue perfusion diagnosis). this will cover you using the impaired circulation as a defining factor. here is a link to the online page for impaired skin integrity so anyone reading this can double check the nanda related factors and defining characteristics for the impaired skin integrity diagnosis. [color=#3366ff]impaired skin integrity

Daytonite, BSN, RN · Jan 17, 2008

the only way that i can think of wording it by using the diagnosis you have is
mrsa- impaired tissue integrity related to infection of av shunt in right forearm as evidenced by pt being cultured for mrsa at shunt site and coming back positive.
ulcer- impaired skin integrity related to pt being bed bound from bilateral bka as evidenced by a non-blanching erythemous area that's hot to touch on the buttocks.
it's late/early so that's the best i could come up with.

when you are developing a nursing diagnosis, and, in particular, committing it to paper, you should verify what you have with a nursing diagnosis reference.

"infection of av shunt in right forearm" is not an accurate related factor for a diagnosis of impaired tissue integrity. related factors are the etiologies, or causes, of the patient problem (nursing diagnosis). they are to be expressed as the underlying pathophysiology when possible of what is going on. "infection" is too broad a term and you will seldom see the word "infection" used as a related factor in the nanda taxonomy. more importantly is, what is the underlying pathophysiology of an infection? see the thread on the histamine response that i posted above and print it out because it will come up often when doing nursing diagnoses for patients with infections. the inflammation response precedes all infections and is the culprit that causes many of the initial symptoms that are seen. those are the symptoms that we generally address until the specific infection takes hold and starts to do more specific damage on a body system.

again, is it not appropriate to list a related factor for impaired skin integrity as "pt being bed bound from bilateral bka." bilateral bka is not an appropriate etiology for a pressure ulcer or a cause for one. again, this goes to the pathophysiology of how a pressure ulcer comes about. many people with bkas do not have pressure ulcers on their buttocks. nor do they have non-blanching erythemous areas that ares hot to touch on the buttocks. some people came about their bkas due to traumatic situations and not a diseased state.

Eirene, ASN, RN · Jan 17, 2008

Thank you so much for your help. As I'm sitting here trying to put my plan together, I'm hitting some road blocks.

For impaired tissue integrity-- my main interventions were:

1. to keep the skin around the packing dry to prevent excoriation.

2. Check the radial and brachial pulses to ensure adequate circulation was still going through the arm (along with cap refill).

3. Keeping the skin clean around the area because of the superinfection.

Am I able to use these interventions even though they are not specified exactly for "Impaired tissue integrity?" Looking back at my careplans, I've noticed many of my interventions are similar to Ineffective tissue perfusion.

And goals! Holy cow. In all honesty, my personal goal was to keep this poor fellow alive through my shifts. I had to go back to square one in nursing and provide him the basic care (skin, nutrition, etc.) because this guy had so much wrong with him. I don't know how to word a goal for the impaired tissue integrity. The goals that I personally thought of was preventing excoriation to the surrounding skin and tissues, keeping the outside dressing dry, and to keep the MRSA localized in the wound. Are these appropriate goals?

I don't want to look like a slacking student nurse because I chose the "more basic" nursing diagnoses and interventions. With all my heart, I believe this gentleman needed the basics. I followed him to the OR for not one permacath, but for TWO because the first one clotted off. We immediately went to dialysis afterward to see if the other would work. He needed basic nursing care as it was not getting done.

Thanks for any help you can offer.

Dani

Daytonite, BSN, RN · Jan 18, 2008

your nursing interventions are treatments for the symptoms that support the nursing diagnosis and you didn't list what those symptoms are. i only know from your first post that you have an infected shunt wound and a pressure ulcer and nothing else. the nanda taxonomy does not list interventions. if you are using nursing interventions classification (nic), by joanne mccloskey mccloskey dochterman, gloria m. bulechek, gloria m. bulechek as a reference you will find interventions that they link to this diagnosis. still, you saw the patient and know what he needs, so you are problem solving this.

there are four types of nursing interventions. those that:

assess/monitor/evaluate/observe (to evaluate the patient's condition)
care/perform/provide/assist (performing actual patient care)
teach/educate/instruct/supervise (educating patient or caregiver)
manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

for each nursing diagnosis you should be able to have at least one of each type of intervention if not a couple within each category. certainly, a handful of the "care" type. do not just depend on a nursing care plan book to write these interventions. check the index of your nursing textbook(s) on wounds and decubitus ulcers to see what information is there. you may find information spread throughout the book. if you have to go out on the internet, look for information on these conditions and see what kinds of treatments you might find recommended as a basis for possible nursing interventions.

goals are nothing more than the predicted results of your nursing interactions. so, for example, if you have an intervention that addresses keeping the wound clean, then a goal is that the wound will be free of infection by such-and-such a date. a long-term goal for impaired tissue integrity is that the wound will be healed. i wrote an extensive post on how to write goal statements on post #157 of this thread: https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html

Eirene, ASN, RN · Jan 26, 2008

Daytonite,

I wanted to let you know that I passed my nursing process! Whew!

One thing that my instructor added is that I should have used "Infection" instead of impaired tissue integrity. I didn't think we were permitted to use a diagnosis that wasn't NANDA approved. Are these subject to the school's rules?

Thanks a million for your help. I don't think I would have passed it without you.

Dani

Daytonite, BSN, RN · Jan 26, 2008

Daytonite,
I wanted to let you know that I passed my nursing process! Whew!
One thing that my instructor added is that I should have used "Infection" instead of impaired tissue integrity. I didn't think we were permitted to use a diagnosis that wasn't NANDA approved. Are these subject to the school's rules?
Thanks a million for your help. I don't think I would have passed it without you.
Dani

Probably. Infection is not an official NANDA diagnosis. You should ask what their rationale is on that. Infection is kind of a term that exists in a haze with NANDA. Some think of it as a medical diagnosis, yet there are instances in the taxonomy where it is used as a symptom. Go figure. In actuality, when you get into practice you can pretty much use it however you want and the NANDA taxonomy is just a guideline. Of course, for school, guess who has all the power? It's just that with the NANDA taxonomy in your hand you at least have a fighting chance to challenge a decision!

Congratulations on passing nursing process! I'm proud of ya! This was kind of a complicated care plan to do.