Nursing Students General Students
Published Sep 4, 2008
mistiffy
125 Posts
Ok, I had a pt who was one day post-op following a L3-L5 Laminectomy and I discovered 2 red areas on her skin (she has been in bed the majority of the time, and was being turned q2h) Anyways, I am using impaired skin integrity as one of my dx's on my care plan, but my ? is, would it be impaired skin integrity, or RISK FOR impaired skin integrity? Im just not sure since she did have those red areas, but there was not any actual skin break down, and I know the goal is to prevent that skin from breaking down.....I dunno I just need some help clarifying that =-)
Melinurse
2,040 Posts
Impaired skin integrity r/t immobility as evidenced by reddened areas over boney prominences.
Of course there are many others that can be thought of for a post-op lami as well. Good luck. And hopfully you'll get alot of responses with alternate ideas. I always loved seeing alot of different ways of looking at and diagnosing the same thing.
NHCNurse
52 Posts
I would also say Impaired skin integrity r/t immobility AMB reddened areas over boney prominences.
Don't second guess yourself girl...you got it!
Daytonite, BSN, RN
1 Article; 14,604 Posts
"is there a problem?" is the first question you must answer. the answer comes from doing a thorough assessment. two reddened areas on the skin that do not go away once pressure is removed qualifies as a disruption of the skin surface and is an actual problem (impaired skin integrity). if the red areas go away when pressure is relieved then you have a case of potential for breakdown to occur which is an anticipated problem (risk for impaired skin integrity).
once you know if you have an actual or potential problem and you are unsure of using any diagnosis, check the taxonomy information (definition, defining characteristics and related factors). for impaired skin integrity the definition is altered epidermis and/or dermis and the defining characteristics (symptoms) are: destruction of skin layers, disruption of skin surface, invasion of body structures.
Thank you guys!!!! I get to second guessing myself like you said and start doubting, lol! The reddened areas remained red when pressed, so its definitely impaired. You know I just started level 2 Med/Surg 3 weeks ago and I already feel like I'm losing my mind! BUT, behind the insanity of it all, I LA LA LA LOVE IT!! Thanks again!
always keep in mind that care planning is problem solving. we have a tool called the nursing process to help us with all our problem solving. print this outline out and always follow its steps in sequence to get through rough spots, especially with care plans, but it works with any situations:
[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
[*]planning (write measurable goals/outcomes and nursing interventions)
[*]implementation (initiate the care plan)
[*]evaluation (determine if goals/outcomes have been met)
Thanks again! I printed that out and I think Im gonna pass it on to my clinical group! As always thanx for your assistance!