NUR 2356 Nursing Diagnosis MDC 1 Online Clinical
Nursing Diagnosis
Write 3 complete Nursing Diagnosis (NANDA) statements for one of your patient’s
... [Show More] admitting or primary diagnoses. Choose statements that relate to a problem your patient is having during this hospitalization. If the goal is not met, what further activity can be attempted to reach the goal?
Nursing Diagnosis Expected Outcomes
SMART GOALS
1 SHORT TERM
1 LONG TERM Nursing Interventions
2 per Diagnosis 4 per each outcome (8 TOTAL)
1.
DDI
Impaired tissue integrity related to altered circulation as evidenced by pitting edema
(Ackley &Ladwig 2008) and (Gulanick & Myers 2014)
1. Patient reports any altered sensation or pain at site of tissue impairment
2. Patient demonstrates understanding of plan to heal tissue and prevent injury
1. Assess site of impaired tissue integrity and its condition. Redness, swelling, pain, burning, and itching are indication of inflammation
2. Assess characteristics of wound, including color, size (length, width, depth), drainage, and odor. These findings will give information on extent of the impaired tissue integrity or injury.
3. Assess the patient’s level of distress. Pain is part of the normal inflammatory process
4. Assess patient’s nutritional status. Inadequate nutritional intake places the patient at risk for skin breakdown
5. Know the signs of itching and scratching
6. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels
7. Identify a plan for debridement when necrotic tissue (eschar or slough) is present
8. Assess changes in body temperature. Fever is a systemic manifestation of inflammation and may indicate the presence of infection
(Ackley &Ladwig 2008) and (Gulanick & Myers 2014)
Patient reports any altered sensation or pain at site of tissue impairment by end of day.
Patient demonstrates understanding of plan to heal tissue and prevent injury by end of week.
2.
2.
Risk for infection related to poor nutritional status as evidenced by ulcer
(Ackley &Ladwig 2008) and (Gulanick & Myers 2014)
1. Client will remain free of local or systemic infections, as evidenced by the absence of copious, foul-smelling wound exudate.
2. Client will maintain normal body temperature.
1. Assess the client’s nutritional status. Clients who seriously lack nutrition (serum albumin <2.5 mg/dl) are at risk of developing infection produced by a pressure ulcer
2. Assess the client for unexplained sepsis. When septic workup is done, the pressure ulcer must be considered a possible cause
3. Assess for urinary and fecal incontince. Sacral wounds are at highest risk for infection
4. Assess pressure ulcer for odor, color, and drainage. Foul smelling may indicate infection
5. Assess the client’s temperature. Fever is considered a temperature above 100.4 degrees F.
6. Monitor the clients white blood cell count. Elevated results indicate an infection
7. Obtain wound cultures, if indicated
8. Provide thorough perineal hygiene after each episode of incontinence
(Ackley &Ladwig 2008) and (Gulanick & Myers 2014)
Client will remain free of local or systemic infections, as evidenced by the absence of copious, foul-smelling wound exudate by end of week.
Client will maintain normal body temperature by end of day.
3.
Risk for ineffective health maintenance related to impaired functional status as evidenced by increased confusion
(Ackley &Ladwig 2008) and (Gulanick & Myers 2014)
1.Client and caregiver will verbalize understanding of the following aspects of home care: nutrition, pressure relief, wound care, and incontinence management
2.Client and caregiver will verbalize ability to cope adequately with existing situation, provide support/monitoring as indicated
1.Assess the client’s and caregiver’s knowledge of and ability to provide local wound care. Clients are no longer kept hospitalized until pressure ulcers have healed
2. Assess the client’s and caregiver’s understanding of the long-term nature of wound healing
3. Assess the client’s and caregiver’s understanding of and ability to provide a High-calorie, high-protein diet throughout the course of wound healing
4. Educate the client and the caregiver to report the following signs indicating wound infection: Fever, malaise, chills, foul-smelling odor, purulent drainage
5. Educate the client and the caregiver regarding local wound care, and allow for a return demonstration
6. Involve a social worker or case manager
7. Educate the client and the caregiver the importance of pressure reduction and relief (e.g., turning schedule, use of specialty beds, use of relief surface where the client sits)
8. Discuss with the client and caregiver the need for in-home nursing care or homemaker services
(Ackley &Ladwig 2008) and (Gulanick & Myers 2014)
1.Client and caregiver will verbalize understanding of the following aspects of home care: nutrition, pressure relief, wound care, and incontinence management by end of day.
2.Client and caregiver will verbalize ability to cope adequately with existing situation, provide support/monitoring as indicated by end of week. [Show Less]