Quick nursing dx question!!!!

Nursing Students General Students

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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 =-)

Specializes in LTC, case mgmt, agency.

Impaired skin integrity r/t immobility as evidenced by reddened areas over boney prominences.:up:

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.

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!

Specializes in med/surg, telemetry, IV therapy, mgmt.

"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!

Specializes in med/surg, telemetry, IV therapy, mgmt.

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:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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)

  • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]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!

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