risk for impaired skin integrity

Daytonite, BSN, RN · Mar 4, 2009

hello everyone. i'm new here. i hope to graduate in the summer, but have gone from making all a's in clinicals/school last semester to c's this semester. any help would be appreciated!
i have a two careplans due. diagnoses: diabetes, copd, pvd. am thinking of fluid volume excess aeb 1+ pitting edema, sob at rest and exertion, and altered labs (hbg, hct). i'm struggling with goals! they must be, "realistic" goals (2 days). the patient also has kidney disease. for second careplan, i'm thinking of, "risk for impaired skin integrity". other abnormal labs: albumin (which i know will support that nanda, and not sure if the other abnormal labs would but they include, glucose, bun/creatine, cbc-rbc, hgb, hct, rdw, lymphs). any advice would be greatly appreciated. my patient is elderly and is a resident in a nursing home and was admitted due to complications with diabetes. i'm not sure if i should choose impaired physical mobility for second careplan or not. she isn't really mobile (just to the bedside commode) at times, adult diapers otherwise. i'm just having trouble tonight. just a little steering would be greatly appreciated!
i have been visiting this site for months now..........enjoy reading and learning! thanks in advance for those that may take the time to respond!
last thought........can you use a medication as aeb......such as lasix for fve? or, is that an intervention?

i think some explanation about diagnosing needs to be done first. doctors and nurses are not the only professions that diagnose. the definition of diagnosis is the resulting decision or opinion after the process of examination or investigation of the facts. if your toilet won't flush you call a plumber (or the apartment maintenance guy if you live in an apartment) to come in and fix it. before the guy does anything he inspects the toilet to see for himself that it, indeed, does not flush. he might also take the lid off the tank and look around before he determines what the problem is, gets out any tools and starts tinkering around and fixing the problem. this inspection, in our profession, is called assessment. determining what a problem is, in our profession, is called diagnosing. getting out tools and starting to tinker around, in our profession, is initiating nursing interventions.

we follow the nursing process which is a problem solving method when care planning. it has 5 distinct steps and if you follow them in the sequence they are meant to occur, rational/logical solutions result. i write about this all the time on this thread: help with care plans: https://allnurses.com/general-nursing-student/help-care-plans-286986.html.

step 1 assessment - think of yourself as a detective. we are always on the lookout for data. the more the better. data is what helps us make our decisions about the patient's care. assessment consists of:

a health history (review of systems) - this patient has diabetes (admitted for complications of the diabetes), kidney disease, copd, pvd
performing a physical exam - 1+ pitting edema (where exactly?), sob at rest and exertion
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - is elderly and lives in a nursing home, is only mobile to a bedside commode (at times) otherwise wears adult diapers (do you mean that she is incontinent?)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - only information given is that she has an abnormal albumin, glucose, bun, creatinine, cbc, rbcs, hbg, hct, rdw and lymphs. stating a lab is "abnormal" is not good enough. a lab is either elevated or decreased and that makes a big difference in what it means. you also need to look up information about diabetes, kidney disease, copd and pvd and see if the patient has any of the signs, symptoms and complications that the textbooks talk about. the lab test results you copied down should be compared with what the textbooks talk about. you should start to put together a picture of what is going on medically with this patient. you need that information in order to help in choosing nursing diagnoses.
reviewing the signs, symptoms and side effects of the medications they are taking - ???

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

sob with exertion
sob at rest
1+ pitting edema
only mobile to a bedside commode
incontinent?

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

activity intolerance r/t imbalance between oxygen supply and demand secondary to copd aeb sob with exertion [more evidence is needed including pulse rates and b/ps]
ineffective tissue perfusion, peripheral r/t interrupted vascular blood flow secondary to pvd aeb 1+ pitting edema
impaired physical mobility r/t activity intolerance aeb only able to transfer to a bedside commode with ___ assistant helping
risk for falls r/t age and presence of vascular disease in lower extremities

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i'm struggling with goals! they must be, "realistic" goals (2 days).

goals can be looked at as being what you predict will happen as a result of your nursing interventions. let me give you a common real world example of some goals that you can identify with.

i have a messy kid. (problem) i tell him, "in one hour i want all your clothes picked up off the floor and put in the dirty clothes hamper in the bathroom." (short term goal) "by dinnertime i want your bed made, the floor swept and the dresser straightened up." (a longer term goal) "go up to your room and start cleaning it right now." (order/intervention). "i want you to get all the clothes picked up off the floor." (order/intervention) "put the dirty clothes in the hamper in the upstairs bathroom." (order/intervention) "put your shoes in the closet shoe organizer." (order/intervention) "get those books and games off the floor and stacked neatly on your desk." (order/intervention)

what you are trying to accomplish with nursing goals and nursing interventions is no different. your stumbling block is that you may not be clear as to what the predicted happening is supposed to be. when you are new at nursing you need to just sit and think about what will happen when everything falls into place after all the interventions have been done correctly. sometimes goals are as simple as the reversal of the symptoms that created the problem in the first place. you must have clearly identified symptoms of the problem which you are applying solutions (interventions) upon and from that you will get goals (results). if any of these elements are not present then there will be difficulty in getting them to materialize.

fluid volume excess aeb 1+ pitting edema, sob at rest and exertion, and altered labs (hbg, hct).

the problem with using this diagnosis is that you identify no cause (etiology. related factor) so there is no rational reason for choosing it. several nursing diagnoses include edema and sob as symptoms.

altered labs (hbg, hct)

is vague. are the labs elevated or decreased? if decreased, the patient could be hemorrhaging which would be

deficient fluid volume

. you have to be specific with your evidence.

risk for impaired skin integrity.

nice thought--where's your evidence that there is a problem? you must always have evidence.

i'm not sure if i should choose impaired physical mobility for second careplan or not.

i addressed this above. your evidence regarding this needs to be a bit more specific.

can you use a medication as aeb......such as lasix for fve? or, is that an intervention?

aeb is always

evidence of a problem

, the problem being your nursing diagnosis. i cannot think of when the use of diuretics would be used as an aeb in nursing diagnostic statements because it is not

evidence of a problem

. a medication is a physician's treatment of a patient's symptom.

we nurses help the doctors carry out their medical treatment orders as well as perform our own independent nursing interventions. in care plans you can have

collaborative

nursing interventions

which means you are assisting the doctor in carrying out his medical plan of care and say, "administer diuretics as ordered by the physician." i've used it as a risk factor for a diagnosis of

risk for incontinence

because it was an underlying cause for potential incontinence.

Magriff3 · Mar 4, 2009

There are some great books on INterventions and problems..look into it..I found awesome ones....at Barnes Nobles etc.

GAstudentNurse · Mar 10, 2009

Thank you!!

GAstudentNurse · Mar 10, 2009

Wow......thank you so much for such great information. It is much appreciated!

GAstudentNurse · Mar 10, 2009

Hello and thanks in advance to anyone that responds. I have a patient diagnosed with Crohn's, Failure to Thrive. She has lost weight (30lbs) in a short amount of time. In my interview and assessment of her, she informed me of also being very depressed and proceeded to talk of her late husband and how life just isn't the same. I feel like I need to choose Imbalanced Nutrition: Less than Body Requirements, but am also thinking of Depression. Can I use depression as AEB? I certainly feel that along with Crohn's, it is affecting her nutritional status. She is also exhibiting unsteady gait. Labs (albumin decreased, RBC, WBC, Hbg, Hct also decreased) She is on a medication for Cachexia as well. She has a history of recent falls. Can I tie all of that into one careplan for Imbalanced nutrition or would I need to separate? Ex: Imbalanced Nutrition: LTBR R/T Crohn's, Failure to Thrive AEB:

1. Recent weight loss of 30lbs 2. Decreased Albumin, RBC, WBC, Hcg, Hct 3. Verbal acknowledgement of having no appetite 4. Unsteady gait (directly related to poor nutrtion??) 5. Depression (which affects appetite???)

I also have another one due on a patient with a Trach. I am choosing, "Ineffective Airway R/T COPD, ARDS AEB:

1. Bilaterally Diminished breath sounds 2. Non-productive cough 3. Increased RR (26) 4. Artificial Airway (???)

Thanks again for any advice. I'm hoping something is going to CLICK soon and I won't have such difficulty with these anymore! Again, much thanks! :)

Daytonite, BSN, RN · Mar 10, 2009

hello and thanks in advance to anyone that responds. i have a patient diagnosed with crohn's, failure to thrive. she has lost weight (30lbs) in a short amount of time. in my interview and assessment of her, she informed me of also being very depressed and proceeded to talk of her late husband and how life just isn't the same. i feel like i need to choose imbalanced nutrition: less than body requirements, but am also thinking of depression. can i use depression as aeb? i certainly feel that along with crohn's, it is affecting her nutritional status. she is also exhibiting unsteady gait. labs (albumin decreased, rbc, wbc, hbg, hct also decreased) she is on a medication for cachexia as well. she has a history of recent falls. can i tie all of that into one careplan for imbalanced nutrition or would i need to separate? ex: imbalanced nutrition: ltbr r/t crohn's, failure to thrive aeb:
1. recent weight loss of 30lbs 2. decreased albumin, rbc, wbc, hcg, hct 3. verbal acknowledgement of having no appetite 4. unsteady gait (directly related to poor nutrtion??) 5. depression (which affects appetite???)
i also have another one due on a patient with a trach. i am choosing, "ineffective airway r/t copd, ards aeb:
1. bilaterally diminished breath sounds 2. non-productive cough 3. increased rr (26) 4. artificial airway (???)
thanks again for any advice. i'm hoping something is going to click soon and i won't have such difficulty with these anymore! again, much thanks!

i understand your dilemma. let me first say that i am not being mean, but when you say "i feel like i need to choose. . ." it tells me that you are not using rational thinking processes. diagnosis is a rational process. there is nothing intuitive about it. it is quite scientific. no crystal balls or tarot cards involved.

how a doctor diagnoses: (1) they take a history of the patient's past health problems, usually systematically by body systems (this is called a review of systems, or ros). (2) they do a physical examination. (3) they will order tests that target what are going to help them identify what the problem might be. (4) they put all the data that they collected together and determine what disease or condition the patient has. a medical diagnosis has very specific signs and symptoms. they look through the data they have collected to see if those are present.

how a (student) nurse diagnoses: (1) we assess the patient: assessment for us nurses consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications they are taking

(2) we list out all the abnormal data this have collected from the assessment that the patient has. (3) we use a nursing diagnosis reference to match this abnormal data with the defining characteristics (this is nanda language for signs and symptoms) of the different nursing diagnoses in order to correctly pick the diagnoses for the nursing problems that the patient has.

care planning is actually the seeking out and identification of the patient's nursing problems and then developing strategies to do something (provide help) for them. we use the nursing process, which is nothing more than a tool to help us do that. when you assess the patient as the first step of the nursing process, you are, in effect, searching for evidence of the existence of nursing problems. this is all very logical and rational. when these elements are present there is no intuition involved. the problems are there as is the evidence proving them. there is no guesswork.

what we, as nurses, are concerned with is the patient's response to what is happening to them. that is a very important concept to keep in mind. you patient may have crohn's disease, but what we are concerned with is her response to it. what physical and psychological responses have come about because of what this change in the anatomy & physiology to her body has done to her? let the doctor worry about treating the actually changes in the anatomy & physiology. our concern as nurses is:

carrying out the doctors treatment orders
treating the patient's response to the disease
assisting her in performing her adls as modified by her disease

the 3-part nursing diagnostic statement is constructed following this formula:

p (problem) - e (etiology, or cause--cannot be a medical diagnosis)- s (symptoms)

you are proposing a diagnosis of: imbalanced nutrition: less than body requirements r/t crohn's, failure to thrive aeb:

1. recent weight loss of 30lbs 2. decreased albumin, rbc, wbc, hcg, hct 3. verbal acknowledgement of having no appetite 4. unsteady gait (directly related to poor nutrtion??) 5. depression (which affects appetite???)

the reason students need to be looking up the pathophysiology, signs and symptoms and complications of their patient's medical conditions (in this case, crohn's disease, failure to thrive and i would also suggest you do some investigation of cachexia) is to learn about these conditions. you are looking to find

why

each of her symptoms occurred.

the r/t part of the diagnostic statement contains your related factors, or the underlying cause of the nursing problem (nursing diagnosis). it

cannot

be a medical diagnosis. a medical diagnosis can be re-written in generic medical terminology, and this is another reason why you need to know the pathophysiology of these medical diseases. if there is depression (a psychological condition) going on you need to research its effect on eating with patients.

aebs (as evidenced by) are the proof of

intake of nutrients insufficient to meet metabolic needs,

the definition of this diagnosis

.

so, by diagnosing her with

imbalanced nutrition: less than body requirements

you are saying that she isn't taking in enough nutrients and the proof of this is a 30 pound weight loss, a bunch of screwed up labwork, and the patient's own statement that she has no appetite (i would make that more specific, such as she states "she does not feel like eating"). is an unsteady gait really related to not taking in enough nutrients? when you see someone with an unsteady gait is your first thought that they have a nutrition problem? i don't.

depression

is a medical diagnosis. like

unsteady gait

, it is

not

evidence of not eating enough.

does she have diarrhea? does she have any abdominal pain or cramping because of the crohn's? diarrhea in people who have crohn's is one of the related factors of this diagnosis. why? the food is propelled through their gi track so fast that nutrients have no time to be absorbed.

your diagnostic statement should look something like this:

imbalanced nutrition: less than body requirements r/t altered ability to ingest and absorb food secondary to crohn's disease aeb 30 pound weight loss in ___ days, decreased albumin, rbc, wbc, hgb, hct and patient's statement that "i have no appetite."

this patient also has

impaired physical mobility r/t nutritional status aeb unsteady gait
chronic sorrow r/t death of husband aeb sadness and statement that "life just isn't the same."
risk for falls r/t history of previous falling and unsteady gait [note: if she has diarrhea because of her crohn's disease, the diarrhea is also a risk factor for risk for falls]

i also have another one due on a patient with a trach. i am choosing, "ineffective airway r/t copd, ards aeb:

1. bilaterally diminished breath sounds 2. non-productive cough 3. increased rr (26) 4. artificial airway (???)

not being mean here, but

ineffective airway

is not an official nanda diagnosis and it really isn't telling us what the problem is. again, look up the pathophysiology, signs and symptoms and complications of copd and ards. copd is a general term for a group of 4 respiratory diseases. was the patient diagnosed with at least one of them? a tracheostomy is a medical (doctor's) intervention for a medical problem and

cannot

serve as evidence of a nursing problem. however, as a nurse, you should look up the complications of a tracheostomy and be prepared to observe for them and be able to treat them if they occur.

bilateral diminished breath sounds, a non-productive cough and an increased respiratory rate are symptoms of

ineffective airway clearance.

the cause, or related factor for this is the presence of an artificial airway (the trach) and excessive mucus (???) or perhaps retained secretions (???). knowing nothing else about this patient makes it hard to know why the

ineffective airway clearance

would be happening.

you could write this diagnostic statement as:

ineffective airway clearance r/t presence of a tracheostomy tube aeb bilateral diminished breath sounds, a non-productive cough and an increased respiratory rate.

you can find information about crohn's, ards, copd and ards on these websites:

merck manual of diagnosis and therapy
http://www.merck.com/mrkshared/mmanual/sections.jsp
web md index list of medical conditions
http://www.webmd.com/a_to_z_guide/health_topics.htm
emedicinehealth list of topics from a to z
http://www.emedicinehealth.com/script/main/art.asp?articlekey=60185

GAstudentNurse · Mar 10, 2009

Daytonite, wow.......thanks for such great indepth information and for your honesty! Both goes a long way! I tried today to utilize your "plumber" scenario to help me! Thanks again!

Can I ask a question? Was it always this easy for you?

Daytonite, BSN, RN · Mar 11, 2009

Daytonite, wow.......thanks for such great indepth information and for your honesty! Both goes a long way! I tried today to utilize your "plumber" scenario to help me! Thanks again!
Can I ask a question? Was it always this easy for you?

No, which is why I am so passionate about helping you guys.