1st semester RN student. Need help with writing goal.

cmurra6745, ADN · Oct 27, 2013

I wouldnt out poor to heal on foot I would be more anatomically specific but besides that seems ok

cmurra6745, ADN · Oct 27, 2013

and as a goal I would out to increase circulation and promote healing enviroment to extremity and prevent further skin deterioration and infection something like that maybe

minniprophett · Oct 27, 2013

Thanks for the info. Would appreciate more feedback from other people too.

Nursing_Mamacita · Oct 27, 2013

I wouldn't say a/e/b MRSA in wound. Be careful with diagnosing. Though the pt may have a dx of MRSA, for your aebs you want to list objective or subjective findings (i.e things you observe or things your pt complains of)

nursek17 · Oct 28, 2013

my goal for impaired skin integrity would be "patient will experience no further skin breakdown during my shift" You do not need an AEB by for your goal only for your diagnosis. As far as your diagnosis I would be more specific for you AEB such as what stage is the pressure ulcer? How do you know that there is MRSA in the wound did they do a wound culture? Say for example its a stage 2 pressure ulcer and you know they have MRSA because in their chart you saw they had a wound culture that came back positive for MRSA you could say

Impaired Skin Integrity r/t decreased circulation secondary to Diabetes Type 2 AEB Stage 2 Pressure Ulcer on Right foot, Necrotic Tissue on Right foot, Wound Culture Positive for MRSA, and a Capillary refill of > 3 Seconds.

(p.s I don't know what foot it is thats just an example!)

Also, If it were me I would just put

Impaired Skin Integrity r/t decreased circulation AEB Stage 2 Pressure ulcer on right foot and presence of necrotic tissue.

*I am not sure what your school prefers but at mine its a personal decision if we use secondary to or not! A Capillary refill proves that they have impaired circulation but that is not your Diagnosis your diagnosis is impaired skin integrity! I am not sure if any of this helps just an opinion :) good Luck! I think all your ideas are right just play around with the words some!

nurseprnRN, BSN, RN · Oct 28, 2013

*I am not sure what your school prefers but at mine its a personal decision if we use secondary to or not! A Capillary refill proves that they have impaired circulation but that is not your Diagnosis your diagnosis is impaired skin integrity! I am not sure if any of this helps just an opinion :) good Luck! I think all your ideas are right just play around with the words some!

Impaired circulation is something a nurse can diagnose by describing impaired capillary filling, cool skin temps, weak or absent pulses, and discoloration.

nurseprnRN, BSN, RN · Oct 28, 2013

I am using Impaired skin integrity r/t impaired circulation secondary to Diabetes type 2 AEB poor to heal pressure ulcer on foot-necrotic in appearance, MRSA in wound, capillary refill >3 sec.
Goal: Patient will have intact skin and prevent further injury of wound to promote healing AEB no new injury to feet, no worsening condition of wound (redness, heat, swelling, pain, further skin deterioration), administering antibiotic
Does this goal work? Am I on the right tract?

1) Administering prescribed medications is not a goal. It's not even part of a nursing plan of care, it's part of the medical plan of care that the nurse is delegated to implement. Nurses are legally responsible to implement parts of the medical plan of care, but nursing plans of care include things that nursing is solely responsible for, autonomously.

2) It's "track," not "tract."

3) You might find it easier to think about this if you use short term and long term goals. Short term would be, e.g. (which is from the Latin "exemplia gratis" and means "for example"), no worsening of the current wound and no new ones. Long term goals might be healing of the present one and ... what else?

4) Evidence is what you use to make your diagnosis. You can also use similar terms to specify what your evaluation criteria are for meeting goals, such as decreasing wound size and depth, drainage, etc.