Making a Care Plan with a risk diagnosis

  1. I really need some answers. I have to present an NCP with the diagnosis "Risk for Infection". The case is about a post-op patient (surgical procedure: cholecystectomy-removal of the gall bladder). So he has an incision which gives potential to infection. Is the diagnosis right if i put "Risk for Infection R/T surgical incision"? or should it be "surgical procedure"?
    In a risk diagnosis you don't have to extend to the a.m.b. part right?
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    About heartilly

    Joined: Jan '06; Posts: 14

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  3. by   Daytonite
    the words you use to form the "related to" part of your nursing diagnosis on this have to do with what potential infections you are thinking about. if you are aiming at a "risk" of a wound infection either of the words "surgical incision" or "surgical procedure" will work because the cause of the infection of the incision was due to the presence of the incision and because the patient had surgery. however, as i was thinking about a surgical patient i was also thinking of the possibility of postop pneumonia which is also an infection. in a case like that i would use: risk for infection r/t surgical procedure. the cause of wound infection and pneumonia would be directly due to the patient undergoing a surgical procedure. if the patient had not had the surgery, the concern for these infections occurring wouldn't even be considered, so the surgical procedure would be the cause of any infection.

    you are correct. in a "risk for" nursing diagnosis, which is an anticipated problem, not an actual problem, you do not include any amb (as manifested by) items. the reason is because the items that follow "amb" are actual, real symptoms that a patient has that are determined during a physical assessment. since these problems don't exist there can be no symptoms of them. however, when you are putting together the nursing interventions for these kinds of nursing diagnoses, you do have to know the symptoms that you would expect to see if those problems did exist and develop your nursing interventions to address each of those symptoms. your nursing interventions will often be things that include monitoring, assessing, observing and evaluating for those signs and symptoms.

    you will find information on writing care plans and nursing diagnoses on these threads on the nursing student forums:

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