Help with MRSA careplan

[jessnurse09]

Hello,

This is my first thread. Hope I'm posting in the right place :)

My pt's medical dx are Pneumonia, +MRSA, and abd. wound dehiscence s/p c-section.

Of course I am addressing the pneumonia first as ineffective airway clearance.My question is, should I now address the wound or the MRSA? The wound is gaping and shows the classic signs of infection, but MRSA is obviously a deadly infection.

And when I do address the MRSA, would I use "Risk for spread of infection?"

I welcome any responses. I think I've stared at this too long. I'm going in circles and making this harder than it really is. Thanks in advance!

[Daytonite, BSN, RN]

a care plan has strategies for solving the problems that the patient has. they are based upon the symptoms that the patient has. symptoms are discovered during your assessment activities involving the patient. you've already determined that one of this patient's problems is ineffective airway clearance which is actually the "inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway" (page 5, nanda-i nursing diagnoses: definitions & classification 2007-2008). that tells me that this patient most likely has some symptoms such as adventitious lung sounds and a cough with sputum production. your care plan will address those symptoms by developing nursing interventions for those things.

is the mrsa a nursing problem? what are the assessment findings? mrsa is not an assessment finding, but a medical diagnosis. depending on your assessment data of this surgical wound there will most likely be impaired tissue integrity. there may also be accompanying hyperthermia or ineffective protection.

what would be the symptoms of an infection that has spread? how would these be different from other symptoms of infection? i would not use risk for spread of infection. however, i think i do know what you are trying to get at. the complications of uncontrolled infection are sepsis and death. the symptoms of sepsis are fever, chills, restlessness, confusion, diaphoresis, anorexia, vomiting, diarrhea, pallor, hypotension, tachycardia, and oliguria. as sepsis worsens, organ systems begin to deteriorate. the diagnosis to use for this is risk for ineffective tissue perfusion: cardiopulmonary and renal.

[jessnurse09]

Thank you, thank you, thank you!!!! The light bulb finally came on! I appreciate your help!