NUR DX question about infection

[sgalvin07]

Hi All,

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

[PsychNurseWannaBe, BSN, RN]

OK... fast and dirty version... It's getting late :)

Risk for diagnoses do not have an AEB because if it did, it would be an actual diagnosis and not a risk for. I never like this question because it confused me as well. I don't know if there is an NANDA for just Infection. But you could do Skin Integrity Impairment r/t surgical intervention to drain infected cyst AEB open wound that measures 2.5 cm x 2.5cm (is there any depth??)

As an intervention you could put wound care, if he is receiving ATB therapy, vital signs, etc.

[sgalvin07]

OK... fast and dirty version... It's getting late :)

Risk for diagnoses do not have an AEB because if it did, it would be an actual diagnosis and not a risk for. I never like this question because it confused me as well. I don't know if there is an NANDA for just Infection. But you could do Skin Integrity Impairment r/t surgical intervention to drain infected cyst AEB open wound that measures 2.5 cm x 2.5cm (is there any depth??)

As an intervention you could put wound care, if he is receiving ATB therapy, vital signs, etc.

Yes to the depth. It's in there just mixed in too close with the rest. 2.5 x 2 x 2.5cm

I personally don't like Risk for diagnosis as they are. Been preached at about them too many times I try to stay away from them. And personally you have my head thinking in another direction and I like it much better. I never thought about going the altered skin integrity route, but that definitely helps get me to the point I wanted to make.. Thank you very much, late or not your words have inspired

[PsychNurseWannaBe, BSN, RN]

Yes to the depth. It's in there just mixed in too close with the rest. 2.5 x 2 x 2.5cm

I personally don't like Risk for diagnosis as they are. Been preached at about them too many times I try to stay away from them. And personally you have my head thinking in another direction and I like it much better. I never thought about going the altered skin integrity route, but that definitely helps get me to the point I wanted to make.. Thank you very much, late or not your words have inspired

:thankya: LOL... just kidding... You're welcome though. :)

[NCRNMDM, ASN, RN]

I know I'm really late here; I apologize for that. No, you can't really use risk for infection when the patient already has an infection. If it has already happened, or is happening, then it is no longer a risk. Also, for future reference, you never have an AEB statement in a risk for diagnosis. This is because there is no evidence that it is occurring because it isn't happening yet. A risk for infection diagnosis would look something like this: risk for infection r/t surgical procedure, open wound on posterior neck, IV lines, and hospitalization. In this situation you could consider impaired skin integrity, pain acute, or impaired tissue integrity.

[nurseprnRN, BSN, RN]

don't ever make a habit of avoiding "risk for" diagnoses, because that can lead you down the path of today is all that counts and i don't have to worry about what might happen to this poor guy later. we do have to worry about what might happen. people are at risk for things all the time, and we ignore that (or looking for that) at our peril..and theirs.