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Discussion

Care plan! i need so much help please :(

Hi I need so much help on my careplan. :(

i had a pt, he had facial cellulitis, his L side of face was swollen but his VS were all good.

he said he had some problems with breathing when he was laying flat. but his RR were all WNL.

i am really having a headache because i have to do two nursing dx on him.

and i had no clues. so please help me.

my dx:

Ineffective breathing pattern related to inflammation of the subcutaneous tissue of left side of the face

and i only can think of one dx. :(

so what do you guys think?

thanks!

Featured Replies

Look at the top of this student nurses page where you posted.., there are stickies for help on care plans and things from Daytonite who is no longer around but helped me very much with my careplans

Sorry about the triple posting. Do you need actual nursing diagnosis or can you do potentials too?

Think of your ABC's.... so airway, breathing, circulation.

What about Pain... cellulitis is painful

Fever (Very common symptom of cellulitis)

Something about skin integrity...

  • Author

yes i need nursing dx that i can do interventions for it.

i only can think of this one:

Ineffective breathing pattern related to inflammation of the subcutaneous tissue of left side of the face

he didnt have fever and his pain was control! thats why it is so hard for me to do the careplan!!! :(

Impaired skin integrity r/t inflammation of skin and tissues

  • Author

"With Impaired Tissue Integrity you are expecting to find open entryway in the skin, incisions, cuts, etc. Often with cellulitis there is weeping of serum from the edematous tissues because they are so swollen. However, the correct diagnosis to use in those cases is Impaired Skin Integrity (Impaired Skin integrity) since only the epidermal areas of the skin are involved. If there is no weeping of the skin and fluid only is being retained"

so i dont think i can use impaired tissue integrity.

but thanks tho!!

"With Impaired Tissue Integrity you are expecting to find open entryway in the skin, incisions, cuts, etc. Often with cellulitis there is weeping of serum from the edematous tissues because they are so swollen. However, the correct diagnosis to use in those cases is Impaired Skin Integrity (Impaired Skin integrity) since only the epidermal areas of the skin are involved. If there is no weeping of the skin and fluid only is being retained"

so i dont think i can use impaired tissue integrity.

but thanks tho!!

LOL I said impaired SKIN integrity :) Good luck!

i would just scower your textbooks... :) Sorry we arent much help. and you can do interventions for at risk nursing diagnosis lol

What about risk for complications r/t disease process?

What kind of pain meds is this guy on? If they are narcotic pain meds, you could do "risk for constipation," or even "Risk for Falls." Also, is he eating/peeing/pooping? Any problems with "Risk for Impaired body image?" or "Spiritual distress?" Even though he's on pain meds, he's still technically at risk for acute pain, too.

Don't get caught up on just once facet of his care! That's a pretty common danger I found myself doing pretty often when I first started doing these care plans. :) Good luck!!!

Don't forget your psychosocial NANDAs too: did he have anxiety about laying down because of fear of breathing difficulty? Did he feel hopeless about his condition? Etc

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