Did i pick good nursing diagnosis' for this patient?

[Shandigidy]

hello, i was hoping i might get a little input. let me start with patient information (some data is slightly altered for confidentiality). 26 year old female in med/surg icu, had tooth pain for 4 months, submandibular swelling began 5 days prior to seeking medical attention. i&d was preformed, 2 molars were removed and 3 penrose drains were inserted at left side of neck. a 4th penrose terminated adjacent to tongue. tracheotomy was inserted and placed on vent (pressure control) due to severe inflammation neck, which was threatening her airway. ng tube was not inserted, so npo. heavy sedation lead to confusion and wrists were restrained due patients attempts to remove vent tubing. throughout day iv sedation and iv pain meds were decreased to point where patient became alert enough to communicate and restraints were able to be removed. the vent was removed and trach collar initiated and maintained successfully. vs averaged bp 100/60, hr 60, rr 12, t 36.5

nursing dx ideas:

risk for infection r/t surgical wound and drains, problem is i know there is already and infection, that's what brought the patient to hospital. can i use it, for the spreading of infection potential?

impaired tissue integrity r/t surgical incision and inflammation response.

confusion r/t restraints, patient pulling on vent tubing.

acute pain r/t surgical incision, debridement, toot extraction

(x2)

what do you think?

[suzers26]

I would think confusion would be r/t mediactions & restraints evidenced by pulling on the tubing, etc. Perhaps something on nutritional status?

Anxiety.....

impaired communication.....

Impaired oral mucous membrane.....

disturbed sensory perception.....

impaired swallowing.....

A few I think of anyway if it helps any!

[tiffanyleigh0212]

I was thinking on the confusion one also and don't think restraints or pulling on tubing would be the r/t IMO.. unless i'm missing something. is it the restraints that is causing the confusion? if it is, then restraints would be a good r/t factor, but if not, i don't believe so. i think the confusion is more r/t the heavy sedation. so maybe acute confusion r/t heavy sedation AEB pulling on tubing (and maybe restraints) i'm still having a hard time seeing that fitting in at all, but then again, it's late at night and i've been studying all day ha!

[SuesquatchRN, BSN, RN]

Look at her slow respiratory rate. Look at the trach.

AIRWAY - artificially remains open. What would apply?

BREATHING - slower 2o probably heavy sedatives, which slow the CNS

Impaired nutrition - less than body requirements. She's NPO. What parenteral nutrition is she receiving?

[Shandigidy]

Thank you for your help, I realized the confusion wasnt right. I was just rushing ideas and hoping to get a quick response. My diagnosis' were do that night via email.

I used "Risk for Injury(self)" R/T confusion from sedative(versed) & analgesic (fentanyl), AEB: patients attempts to pull out trach tubing.

[tiffanyleigh0212]

that one sounds great!