You ask what is wrong with how you are trying to come up with nursing diagnoses? The problem is that you are not organizing the data that you have collected. At least, not as I can see. You should have gone through the patient's chart and copied down all kinds of information from her history and physical, operative report, information that might have been sent over from the acute hospital, as well as the various assessments that were done by the nurses in the skilled nursing unit where this patient now resides. Having worked for a number of years in skilled units I can tell you that she is there for skilled nursing care (per Medicare guidelines) and the savvy people of the facility would have made sure that the proper documentation to support her skilled status and need for nursing care is going to be in that chart of hers. They have to have a documented care plan to support her need for care--or Medicare won't pay for her stay. So, she is there because she needs nursing help. Then, you should have done your own history, review of systems and physical assessment. Of all this data, some of it is not going to be normal. It is the abnormal data that is going to form the basis for choosing any nursing diagnoses. Please re-read Section I of your Ackley nursing diagnosis handbook
again. She (and Ms. Ladwig) very thoroughly explain the nursing process, breaking it down into ADPIE. Under the "D" of ADPIE (Step 2: Nursing Diagnosis) they talk about how to formulate the nursing diagnosis, listing your symptoms (abnormal data), clustering them, and selecting a nursing diagnosis label for them. Please remember that you may not find some of your symptoms in Section II of the handbook (the alphabetized list of symptoms, problems, medical diagnoses, procedures and clinical states). Try converting some of the data you have into medical terminology
terms and then you will be likely to find those symptoms in that listing. As long as the definition
of the nursing diagnoses seems to sound correct, the outcomes listed under the diagnoses seem right, she has one or more of the defining characteristics and one of more of the related factors then you have most likely got a valid nursing diagnosis. You can verify this by browsing through the outcomes and the nursing interventions that are listed. Do they sound like things that fit your patient? Not all of them will pertain to her, but some may. Some of these diagnoses can fit very broad categories of problems that patients are having. Your patient doesn't have to have all
the defining characteristics to qualify for you to take on a particular nursing diagnosis.
I have to correct your perception that this patient is basically there for monitoring of the wound sites and wound care. This is not true. Having worked in skilled care myself, I can tell you that the reason is more likely because nurses and her doctor, while she was in the acute hospital, made the assessment that she was going to be unable to care for these wounds herself. There may have been concern that she would not be able to follow directions or perform the wound care as prescribed. Maybe she has physical problems inhibiting her from performing the wound care herself. This should be something to discover as part of your assessment process Many people having this same problem go home and care for themselves without needing convalescent care in a skilled nursing facility. So, things are lacking with this patient's ability to get her care done that you have missed.
I recommend that you go through whatever assessment items you have on paper and do as Ackley and Ladwig suggest--underline the abnormal data. As you think on this, add some things that you might have observed about this lady and forgotten to include. I'm saying, put it on paper. I put them on a Word document on the computer so I can move it around and not have to erase and re-write it all the time. You have to do this when you are writing care plans
, particularly if you are getting graded on it. When I am helping a student develop a list of nursing diagnoses, I make a list on an open Word document of all the abnormal data they have given me. I use "cut" and "paste" commands to cluster the data. Then I start looking at nursing diagnoses. I have a copy of Nursing Diagnoses: Definitions & Classification 2005-2006
published by NANDA International that I use to verify defining characteristics and related factors because it's smaller than Ackley and Ladwig and easier to handle. I type a nursing diagnosis over a cluster of symptoms that seems to fit. Then I go to my copy of Nursing Diagnosis Handbook: A Guide to Planning Care
, 7th Edition, by Betty J. Ackley and Gail B. Ladwig and look at the same nursing diagnosis to check out the outcomes and nursing interventions to see if I've got a hit or a miss. Once you've got a hit, the remainder of writing the care plan is choosing nursing interventions that address the abnormal symptoms that are listed in the nursing diagnostic statement. Then, of course, you probably also need to supply the rationales for your instructors.
Does this make sense now? Is that of any help to you?
From what you have given in your post, your patient has
- Impaired Skin Integrity R/T surgical intervention AEB wounds on sternum and (left or right) thigh
- Ineffective Protection R/T surgical intervention AEB purulent drainage from wounds on sternum and (left or right) thigh. [I added the purulent drainage since it is mostly likely present even though you didn't mention it. Are there other symptoms of infection such as odor or color to the drainage, positive blood cultures, fever, would culture reports that I'm sure the skilled nursing facility did, etc.?]
Any other diagnoses you find will be based on what you extract from other data you have collected on her. Look at what the medical diagnoses were and see if you can find any of the same symptoms
of those medical diagnoses that you may have missed in your initial assessment. Use those same symptoms (not the medical diagnoses) to look for more nursing diagnoses in Ackley and Ladwig. Good luck!