So I am trying to come up with two priority nursing diagnosis' for diverticulitis. My patient was admitted 5 days after back surgery for fusion of her lower lumbar disks so she has and incision on abdomen and one on her lower back as a result. The incisions are clean and dry but slightly reddenned. She developed lower left quadrant pain, had a low grade fever, nausea and vomiting and a few occasions of rectal bleeding. She had a CT scan showing fluid in the pelvic cavity. She had an increase WBC count and decreased H&H, and decreased NA+ and Cl-. So here is my question, I am trying to figure out nursing diagnosis for her and I thought that Impaired Tissue Integrity because of the diverticulitis which is leaking into her abdomen which could lead to further infection, however my professor said that wasn't the primary the primary would be Impaired Skin Integrity because of her incisions.... I am so lost right now, can anyone tell me how this conclusion was come to or help lead me to understanding it. I am confused because she wasn't admitted to the hospital and there really is nothing related to the incisions that I am seeing would help her with her problems that she is in the hospital for which is her diverticulitis. Sorry if this sounds jumbled I am just so confused right now.
Mar 19, '11
If the patient has intestinal contents spilling into her abdomen, and she already has a fever, my first concern is for sepsis. She may have impaired tissue, which isn't good, but if she has sepsis, that can kill her! What are her other VS like? Is her BP down and RR up? Any shift in mental status? Even if these signs haven't happened, if you know she has intestinal contents in her abdomen, that's one of the most common causes of sepsis. If I were a nursing instructor, that's what I would be looking for in a care plan. In regard to the incisions, she definitely has impaired skin integrity because her skin is already cut open, even if sutured back together (it hasn't healed up yet). If the incisions are red 5 days after surgery, that doesn't sound so good; they may be infected. That could also be causing the fever. Any break in the skin is an invitation to infection, that's always a dead giveaway on a care plan; always always always include it! It's what the instructor is looking for. And it's also good to make note of in the real world :-)