Care plan question!

Daytonite, BSN, RN · Mar 10, 2009

what is this "same boat" you are talking about? the first thing you should do is educate yourself about cellulitis, it's pathophysiology, signs and symptoms and complications. you need to know that information to continue any further. next, you need to assemble all the assessment information you have about this patient. assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications they are taking

if this is a hypothetical patient then looking up as much information as you can find about cellulitis will be very important.

lists of nic (nursing interventions classification) were compiled by mccloskey & bulechek. lists of noc (nursing outcomes classification) were compiled by moorhead, johnson & maas. they are organized by the approved nanda nursing diagnosis list of approximately 188 nursing diagnoses. each nic and noc was given a code number. for example, if you happen to have a copy of nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson and meridean maas you will see that at the front of each listing of outcomes (under where it list indicators: for an outcome) is a 5 digit number. that is the noc code the instructor is referring to. these codes are used to input into computers so the entire wording of the noc doesn't have to be typed into the computer.

i only have the noc codes here at home. what you have posted is two 3-part diagnostic statements. nics involve your nursing interventions and you have listed none of those. nocs involve your goal or outcome statements and you have listed none of those either. i can't code what you didn't provide.

if you need two more nursing diagnoses you need to look at the signs and symptoms that the patient has. diagnosis is based upon assessing the patient and it is abnormal data that become the evidence of nursing problems. nic and noc comes directly from what you have diagnosed.

if you need more help you are going to have to provide more information about this patient.

impaired skin integrity r/t inflammatory process eb presence of infection on thigh.

your

eb

must be evidence, proof, of the impaired skin. anyone coming along and reading your diagnostic statement should be able to understand what is going on and get a picture of the situation. i'm reading that this patient has some disruption in their skin because of inflammation. i'm ok with that. i get to what the evidence is and i see "

presence of infection on thigh

". this should be a description of the cellulitis, but that is not what it sounds like. first of all,

infection

is a medical diagnosis and you cannot use a medical diagnosis like that in a nursing diagnosis statement. second,

infection

, as a medical diagnosis, is not a symptom. what goes after

eb

in the nursing diagnostic statement is symptoms of the

impaired skin integrity.

this is where you should be describing what the cellulitis looks like: length, width, color, depth, drainage.

acute pain r/t injury agents e/b swelling and inflammation of thing

the

r/t

is the related factor, or the cause, of the

acute pain

. what is an

injury agents

(beside the wording you copied out of a care plan or nursing diagnosis book)? do you understand what that means? if you also read the definition of this diagnosis you would have read that for pain to occur there must be

damage to tissues

. what is causing the damage to the tissues? in other words, what is

the injury agent

that is causing the pain for this patient? isn't it also the cellulitis (inflammation process)? say that. the wording in the nanda guideline "injury agent" in merely that--a suggestion or guideline. they can't list every injury agent that could cause pain for someone.

your

e/b

must be evidence, proof, of the

acute pain

. again, anyone coming along and reading your diagnostic statement should be able to understand what is going on and get a picture of the situation. i'm reading that this patient has pain because of an injury (already discussed how to be more specific about that) and that the pain can be described as

swelling and inflammation of thing

. well, that doesn't make any kind of sense to me. when i am in pain i hurt and let people know it and i might describe it! when i had gallstone attacks i told people it felt like a knife stabbing me right below my right ribcage clear through to my back and it was hard to take a deep breath. is that a descriptive picture? assessment and description of pain includes the following (you might want to copy these down):

where the pain is located
how long it lasts
how often it occurs
a description of it (sharp, dull, stabbing, aching, burning, throbbing)
- have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
[*]what triggers the pain
[*]what relieves the pain
[*]observe their physical responses
- behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
- sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
- parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness