Question about Nursing Care Plan

idahostudent2011 · Jan 15, 2011

The care plan is not about the medical dx, but the nursing dx. Look up skin integrity in your nursing diagnosis handbook. What are the risks of skin breakdown being a parapalegic, diabetic, chf, edema 2+? what do you do to make sure that the person doesn't get skin breakdown? Are there pressure points that need to be monitored? how about the condition of the skin?(edema) what about friction? What about teaching the patient about monitoring skin condition? You really need that book to help you with this. There are a couple of book that help. My favorite is called Nursing Diagnosis handbook, Betty Ackley, 9th ed. It is fairly expensive, but is is well worth it. You can get it off of Amazon.com. There is a lot in a care plan to consider, good luck!

Shanna M · Jan 15, 2011

So the etiology part of the care plan never involves medical reasons for the nursing diagnosis, only the signs of that medical diagnosis that the PT is exhibiting? I know that the nursing diagnosis is never the actual medical diagnosis but I was unsure if I could say that the PT is at risk of skin breakdown due to being Diabetic.

Shanna M · Jan 15, 2011

I think it's important to note that the Pt is at risk for skin breakdown because he is Diabetic so I'm not sure how I could incorporate that into my care plan, maybe I'm getting too far ahead of myself. What exactly is it about having Diabetes that puts Pt's at risk for skin issues? Is it poor circulation? So maybe a possible cause could be poor circulation rather than listing Diabetes?

Jonathank · Jan 16, 2011

So the etiology part of the care plan never involves medical reasons for the nursing diagnosis, only the signs of that medical diagnosis that the PT is exhibiting? I know that the nursing diagnosis is never the actual medical diagnosis but I was unsure if I could say that the PT is at risk of skin breakdown due to being Diabetic.

r/t an NDX (mandatory) s/t a MDX (optional)

Jonathank · Jan 16, 2011

I think it's important to note that the Pt is at risk for skin breakdown because he is Diabetic so I'm not sure how I could incorporate that into my care plan, maybe I'm getting too far ahead of myself. What exactly is it about having Diabetes that puts Pt's at risk for skin issues? Is it poor circulation? So maybe a possible cause could be poor circulation rather than listing Diabetes?

You seemed to have missed where the other poster was giving you the hint that paraplegia is probably a much bigger short term issue relating to skin integrity than DM.

Shanna M · Jan 16, 2011

No I added that into my care plan already that was actually the first reason that I listed, but I want to make sure that I am thorough and don't miss anything. I thought it might also be important to note that because the Pt has DM that also causes them to be at risk, but maybe I don't need to go that far, I don't know.

ImThatGuy, BSN, RN · Jan 16, 2011

The paraplegia and the edema are your biggest problems with the impairment of skin integrity. The DM is rather not so much a causal factor as it is one that will impair healing of the issue if you examine it from a cause and effect approach.

Try something like Risk for Impaired Skin Integrity R/T inability to change body positions AEB paraplegia or however your teacher tells you to phrase that if not as paraplegia.

If the skin integrity is your primary diagnosis then paraplegia is your primary cause.

dudette10, MSN, RN · Jan 16, 2011

I, too, would go with paraplegia (inability to change positions) as the primary related factor. After all, risk for impaired skin integrity for DM patients is r/t neuropathy. Because this patient is paraplegic, it would be redundant, IMO, to include DM neuropathy as a related factor.

Shanna M · Jan 16, 2011

Ok thank you this has been helpful :)

Rachel Thome · Jan 17, 2011

I had this same question when I was working on my care plan...I'm wondering if we are taking the same course b/c all the criteria are the same (DM, pitting edema, CHF)?? I am at GRCC. I couldn't figure out how to fit in DM as a r/t factor so I stuck with immobility as the primary but didn't know what to do about the edema either. How is that a risk factor for impaired skin integrity and what interventions are appropriate to help? I just put ROM q 2 hours b/c you can't elevate due to CHF right? I don't think mine is that great but hopefully we will go over them in class!

Shanna M · Jan 17, 2011

haha yes we are :) I'm also at GRCC. Small world I wanted to put that DM in my plan somewhere to but I guess it comes down to priorities and we only really need 2 r/t causes and apparently the edema takes priority for skin breakdown over the DM. Edema Puts a Pt at risk for skin integrity impairment because when the skin is stretched taughtly over the edematous area it is subject to crack or weap fluids putting the skin at risk for breakdown. You can elevate the Pt's legs even though they have CHF just not while they are lying in bed. They can be elevated while the Pt is setting up in a chair. So the interventions that I put r/t the immobility were (and I think I got carried away further than I needed to) turn Pt q2 hours while in bed use pillows with repositioning, get Pt out of bed and have them sit up for 10 min TID- my rationale for this is b/c he in only tolerating 15 min BID and we want to increase his ability to stay up so I want to slowly incorporate him sitting up more frequently, use appropriate skin hygiene products/skin protectants, thoroughly cleanse/dry the skin especially after elimination as stool/urine breaks the skin down, have the Pt eat adequate protein as diets that don't have adequate protein are more susceptible to skin breakdown. I think I put some other things in there too but I'm trying to rush and type this up before I have to get ready for class. The ROM you listed I think is also a good one, I was going to include it on my care plan as well but I ran out of room lol. Good Luck!