I'm not exactly new here I've been lurking, absorbing, reviewing alot of information on here and I finally have a question of my own regarding a nursing diagnosis.
Slight background of situation: Pt. had infected sebacious cyst on the back of his neck for 2 weeks and had been on antibiotics for a week prior to admission. Originally he came in because of his pain the in neck with accompanying chest pain. Ended up having a minor MI at the same time. Fast forward 3 days and he underwent an I&D of the infected cyst. Ended up with a 2.5x2x2.5 open wound to drain following the procedure.... Thats where I came in to take care of him in clinical.
1). If you were to write a NUR Dx / care plan related to the infection. Is it still a Risk for Infection
even though there clearly is an infection......or was an infection? I'd assume I'm doing my care plan in terms of the future moving forward as I was never in direct patient care prior to the I&D. Therefore it would be a risk for infection based on the present open wound
And if so, does the following sound about right?
Risk for Infection R/T open wound on posterior neck AEB open wound measuring 2.5x2x2.5cm, S/P surgical incision and drainage of infected sebaceous cyst, and temp. of 99
Yes, No, Close? Would I even put the temp of 99 as part of the AEB? As it is only slightly elevated and I've noticed in some hospitals they accept 97.8-99 as WDL.. So this could be his normal body temp, or if we use the standard 98.6 it is still slightly elevated.
HOWEVER, if I were taking care of the patient at the time the infection was still there, say the day of the I&D, would it still be Risk for Infection, even though there clearly is an infection at the time. End of novel, I tend to be long winded