lschroederm1

Thanks so much KrCmommy522! This was very helpful and I made changes accordingly! I do have a NANDA book and mine is Ackley as well. I try to steer away from using that book because I tend to write exactly what their interventions and outcomes are and my care plan doesn't end up being individualized. "You want the pt and assessment to drive the diagnosis." I am definitely going to apply this moving forward. Thank you for your kind words and input.

Soo I need your help guys! I have a picky instructor who keeps tearing apart my care plans. I have no trouble with the assessment part and figuring out the diagnosis but her thing is that we need to have 2 outcomes with 4 interventions related to how you will achieve that outcome (which is NOT as easy as it may sound)! Here is my issue. My patient had an arthroscopy to fix a rotator cuff injury. She is relatively young with no other major problems. We discussed that impaired skin integrity is a problem, as well as risk for infection and impaired comfort. She does not allow us to do risk for as a diagnosis if our patient's have active problems so this is what I've got. I do realize impaired skin integrity may not be the best choice, but I discussed it with my instructor so I'm going for it. Please help me out! Also, my patient was discharged during my shift today but I still did implement teaching because she lives alone and will need to change her dressing in 2 days. Diagnosis: Impaired Skin Integrity r/t arthroscopy AMB a foam tape dressing Outcomes: (1) Pt will verbalize importance of good skin integrity by discharge date SN will educate pt on importance of eating a well-balanced diet to support wound healing. Pt will describe need for hydration so the wound receives proper oxygen and nutrients to heal. SN will educate patient on keeping skin clean and dry (2) Pt will maintain skin integrity during hospital stay. Pt will be assisted to reposition every 2 hours. SN will monitor the condition of the skin at least once a shift to assess for erythema, edema, and drainage Feel free to tear this one apart and give me any feedback! I need a couple more nursing interventions without sounding too repetitive.