Care plan assistance

  1. I'm sure something like this has been asked before, I am having problems with care plans, and while I admit some responsibility for the problems myself I also feel my instructor has some issues.

    The main thing I wanted to ask is I used Risk for infection r/t surgical procedure, as evidenced by surgical wound now without dressing.

    In the postings I have checked it seems that risk for infection r/t surgical procedure is something I could use, but she marked this wrong, saying it had to be

    Risk for infection r/t break in skin, r/t surgical procedure, as evidenced by incision on L knee measuring 5 inches with slight redness and swelling, no drainage

    :o
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  2. 2 Comments

  3. by   EricJRN
    A risk diagnosis should just have two parts - the diagnosis and the R/T. No AEB for a risk diagnosis.
  4. by   Daytonite
    whoa! i'm puzzled at your instructor's response to you. i would hate to disagree with her, but the only information here is coming from you. if this is truly what your instructor told you, the information is blatantly wrong. i would hate to think that your instructor doesn't understand how to choose and classify nursing diagnoses.

    a "risk for" diagnosis never has aeb items connected with it because a "risk for" diagnosis is about an anticipated problem. if a problem already exists, then you can't classify the patient's symptoms (incision on l knee measuring 5 inches with slight redness and swelling, no drainage) with this kind of diagnosis. with an incision on the left knee that measures 5 inches with slight redness and swelling and no drainage you have impaired skin integrity r/t surgical intervention aeb incision on the left knee that measures 5 inches with slight redness and swelling and no drainage.

    to use risk for infection r/t surgical procedure what you have to do is base all the interventions for the use of this diagnosis on the potential symptoms that would occur in an infected surgical wound (if that is where you would expect an infection to occur). but be clear here, redness and swelling are signs/symptoms of inflammation, not infection. make a list of the symptoms of infection. we're talking about fever and pus. what your nursing diagnostic statement really would look like is risk for infection r/t surgical procedure aeb signs and symptoms of wound infection [listed out]. however, all of the part in bolded orange never appears in your written out care plan and nursing diagnosis. but you do keep it in the back of your mind when writing your nursing interventions for this nursing diagnosis. the only kinds of nursing interventions you can write for this kind of diagnosis pertain to monitoring for those signs and symptoms, reporting them to the doctor or doing things that will prevent those things from occurring. and, that's about it.

    the way i see it you can use both diagnoses (impaired skin integrity and risk for infection). the only thing you can do for the redness and swelling of the wound incision is to maintain sterile technique when changing dressings (that would be an intervention under impaired skin integrity), and continue to monitor the appearance of the wound (that could come under impaired skin integrity as well as the risk for infection).

    i wouldn't confront your instructor. just change the nursing diagnoses on the nursing care plan. i am always reluctant to use "risk for" diagnoses when there are actual patient problems already. "risk for" are for problems that could and in all likelihood the patient is in danger of them happening. you can include a nursing intervention to monitor for signs and symptoms of infection under the impaired skin integrity nursing diagnosis and that handles the issue of possible infection and does away with using risk for infection.

    make sure you read the posts on these two stickys regarding the choosing of nursing diagnoses. every nursing diagnosis has defined criteria that your patient must meet in order to use it:

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