![]() Use careful sterile technique - of what procedure(s)?Įncourage consuming ensure to increase protein & therefore skin healing. Minimize the exposure of skin to moisture - are you talking about this incisional hernia repair? Why does it need to be free of moisture? Are you referring to the skin or the open hole that is taking forever to heal? Is there any drainage? Monitor lab values - what labs relate to impaired skin integrity? Where is your assessment of the evidence of the impaired skin? If I classify the interventions you listed into the 4 types, this is what they classify to:Īssess the nutritional status - your diagnosis is impaired skin integrity. Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver) Teach/educate/instruct/supervise (educating patient or caregiver) Interventions are of 4 types and address the symptoms (evidence) that support the diagnosis:Īssess/monitor/evaluate/observe (to evaluate the patient's condition)Ĭare/perform/provide/assist (performing actual patient care) So, make a list of what it is that is the evidence that proves the diagnosis exists. You need to know what you are focusing your treatment (nursing interventions) on. Since you really didn't list the evidence that supported the diagnosis I can see why you don't seem happy with your interventions. Your aeb (evidence of the problem) should be a description of this open wound, measurements of it and any drainage.Īctually, a better diagnosis to use, if I understood your post, is What do you mean by and/or excretions? This is a problem, so you know what the cause of the problem is or you don't. This wound is healing by second intention (from the inside out) and it will take months for this to finally heal and close over. When a surgeon cuts into the body to repair a hernia, there is impaired tissue integrity. Impaired tissue integrity is the diagnosis that needs to be used. Once the subcutaneous tissue is involved, Impaired skin integrity is only used for wounds that only go as deep as the epidermis and heal in a week. I had to put a diagnostic statement together based on what you posted.impaired skin integrity r/t excretions and/or excretions secondary to incisional hernia repair with mesh insertion aeb open abdominal wound. I have been working on this for a while and am getting brain freeze I guess because I feel like I'm hitting a brick wall and can't think of any more. So far I have: teach skin & wound assessment to monitor for infections & complications individualize plan according to pts skin condition & preferences teach pt why a specific treatment has been selected assess the nutritional status obtain consult with wound/ostomy specialist minimize the exposure of skin to moisture encourage consuming Ensure to increase protein & therefore skin healing monitor lab values and use careful sterile technique.Īpparently there are a lot of interventions that I have missed. I have several nursing interventions with rationales but need more. She has been on TPA feedings with only clear liquid po. Her abdomen is still open and healing and has 2 pouches which have been leaking stool, which is where the dx comes from. She originally was admitted for fistula repair, incisional hernia repair with mesh insertion. ![]() The pt has been an inpatient for several months. The diagnosis is impaired skin integrity r/t excretions and/or excretions. ![]() I need some help with a care plan I am doing.
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