I need help on my lst concept mapping on skin assessment..
My pt has hx. DVT/anemia/Lupus/Diabetes/Gastric Ulcer/HTN
He just got surgery done to remove his blood clots on his lower extremity.
Here is my nursing diagnosis according most important-least
1. Risk for infection.. r/t surgical incision/-diabete/anticoagulant durgs....
2. impaired skin integrity
Do I have orders right? Any suggestion is appreciated. Thanks a lot!!
The way we were taught to prioritize them were ABC's first then safety..etc...Now I just graduated so perhaps some of the more seasoned nurses have a better suggestion but...I would probably have picked something like:
risk for fluid volume defecit r/t low RBC (can't use anemia as it is a diagnosis so you have to use something that refers to it.)
acute pain r/t incision
risk for infection r/t incision
impaired skin integrity r/t incision, bedrest
Hope this helps. Writing careplans was not my strong point. I know what to do and how to take care of my pts, but for the life of me can not seem to put it under NANDA and write it on paper in a plan form. Good luck to you!!
Thanks for reply.... Sorry, but what is ABC? Airway breathe Cardiac???
Also the pt is on 1.2 L fluid set and 1800 Cal Diet.
We were told to pick out 2 physiologic, (one should related to skin)1. psychosocial..
Use skin one for Concept Mapping..Care plan has taken me soo many days and I'm still working on it..
I was always taught to do physical needs first, then psychosocial needs. Actual needs first, then risks.
There are lots he could have:
- Risk unstable blood sugars
- Risk impaired skin integrity r/t immobility, chronic disease, diabetes, nutritional deficits
- Infection r/t surgical incision, diabetes, nutritional deficits, immobility (don't think anticoagulant leads to infection)
- Risk bleeding (anticoagulant therapy, surgical incision)
First off, you've got a problem with one of your diagnoses. There is no NANDA diagnosis for depression. You will have to look at the symptoms the patient is having for the depression and use those to find other nursing diagnoses to address problems (s)he is having relating to the depression.
Secondly, any diagnosis starting with the words, "Risk of" is what is called an anticipatory problem and does not yet exist. So, in the hierarchy of priorities it is listed last.
Therefore, based on what you have listed and removing the nonexistent diagnosis, the order should be:[list=1][*]Impaired Skin Integrity[*]Risk for Infection Here are some links to information already on the allnurses forums to help you with prioritizing your diagnosis lists as well as how to chose a nursing diagnoses. I am also including a link to a listing NANDA diagnoses. - Sequencing and prioritizing of nursing diagnoses on written care plans - Nursing Diagnosis Troubles http://www.nursingstudio.net/2005/03/20/nanda-nursing-diagnoses/ - a complete list of NANDA nursing diagnoses organized by Gordon's Functional Patterns
Please read over the information in these forum threads on care planning:
[*] - Health Assessment Resources, Techniques, and Forms (in Nursing Student Assistance Forum)[*] - Desperately need help with careplans (in Nursing Student Assistance Forum)[*] - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum) If you are still having further problems with this assignment, ask and I will help you.
Much appreciated. Thanks for those links and they really did great help on my confusion about care plan and RNSG dx.
My final RNSG Dx..
1, acute pain r/t incision, surgery
2. impaired skin integrity
3. infeective role performance
Does it make moare sense now??
I would change the order to:[list=1][*]Impaired Skin Integrity[*]Acute Pain R/T surgical intervention[*]Ineffective Role Performance Under both Maslow and Gordon, this is the sequence these nursing diagnoses would be listed in priority.
You don't list your "related to" items or "defining characteristics" for the Impaired Skin Integrity or the Ineffective Role Performance. You have determined these elements already, haven't you?
Yes, I have listed r/t and AED on my paper. Thanks again, Daytonite. Once I'm done with my lst paper (clock is kicking... ), I'm gonna go through all the links you gave me AGAIN. If anything confuses me again, I will ask you for sure. !!!!
That order is because pain is considered a "psychosocial" need and not a physical need.
Pain is listed second below Impaired Skin Integrity because under Maslow's Hierarchy of Needs the physiological need for nourishment of the skin and tissues (in order to heal) comes above satisfying pain which is an issue of comfort. Under Gordon's 11 Functional Patterns Impaired Skin Integrity comes under the Nutritional-Metabilic Functional Health Pattern (#2 out of the 11), whereas Acute Pain comes under Cognitive-Perceptual (#6 out of the 11). Ineffective Role Performance is a self-esteem need under Maslow which is on the second tier of the pyramid on his hierarchy. That is the rationale behind the way I sequenced them.