Question about nursing diagnosis 'related to' factors

aeris99 · Sep 19, 2015

My question is this.. How do I choose what this patient's 'related to' factor is? It could be due to any and all of those. Do I just select one to write my nursing diagnosis for? Is there a level of importance I should place on those factors? I'm assuming physical immobility would probably be the biggest one, but it certainly isn't the only.
Thank you! This community is the best!

All of those are risk factors for impaired skin integrity. Does this patient have an actual breakdown in the skin or are you concerned that it might become a problem? Start there.

Then put your factors into a list going from most important to least. Use a framework like Maslow's, ABC's, urgent vs emergent, etc.

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HisKonstantine · Sep 20, 2015

If this were my care plan, I would choose related to immobility because that's the most likely cause of skin breakdown. Yes, being overweight and receiving radiation can also cause breakdown but it isn't guaranteed. All caretakers must be vigilant about turning q2h, skin care, and incontinence care (if applicable) in order to avoid the breakdown. It can happen very quickly even with the best care.

This is a case of which one is most right while they are all absolutely correct.