Help-difficult CP

  1. I thought I was done asking for help for care plans as I've done a good job on the last couple, but this one is tough. My patient only has a few ineffective behaviors that I can use on my dx list. He's a rehab patient that had melanoma surgery and has a wound vac on the rather large area on his back. He has also had a couple skin grafts from his upper legs and abdomen. Anyway I was going to use Impaired Skin Integrity R/T mechanical factors AEB open draining wound on left upper back. Would this be ok since it is covered by the wound vac and there is no good Related Factors to use in our Nursing Dx Book? (we are supposed to use one from the book) I'm wondering if we can use something like related to cancer surgery or not?
    I also have a Risk for infection R/T invasive procedures, but we're not suppose to use Risk fors yet. Maybe I can use something that has to do with him wearing glasses or hearing aid. His other IB are dry, brittle, thinnning hair, small skin discoloration, slow tugor, intermittant pain in the wound vac area (less than 3 months), needs assistance getting out of bed (only because its an air bed-client is pretty mobile and does his own ADL's), and he had a slight elevation in temp on Thurs (100), but not friday. Any ideas? I am supposed to have 2 care plans again this week, but will be lucky to get 1 good one...
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    About Medsport, LPN

    Joined: Sep '06; Posts: 383; Likes: 22
    Specialty: 7 year(s) of experience


  3. by   Daytonite
    i would change the diagnostic statement on the impaired skin integrity to:
    impaired skin integrity r/t surgical disruption of tissues aeb draining surgical wound on left upper back and healing donor sites on legs and abdomen [don't forget about them]
    yes, you would put all your nursing interventions for the wound drainage and wound hemovac under this diagnosis. don't forget to also include interventions to monitor the healing of the donor sites on his legs and abdomen.

    with the elevated fever you could do:
    ineffective thermoregulation r/t surgical trauma aeb fluctuations in body temperature (100 degrees on thursday, normal on friday)

    also, is he on any kind of pain medication?
    acute pain r/t surgical incision aeb patient statements of pain in surgical area
    why is he on a air fluidized bed? patients are not placed on these beds unless they have skin breakdown or skin breakdown is attempting to be prevented. is it because of the surgery?

    since this patient has cancer, did he mention anything about knowing how this cancer works? you may be able to do a knowledge deficit with regard to giving him information about melanoma. and did they get it in time? most people don't learn about the seriousness of checking moles on their body until they have a problem with one. here's a link to information on melanoma:
  4. by   Medsport
    Yes, he is on some pain meds and anti-depressants. I came up with Acute Pain R/T physical injury agents secondary to melanoma excision AEB patients statements of pain of the upper left back area. Your R/T does sound better, I hope its ok to use it because its not listed in my NDB (prentice hall, 8th ed.).
    I also came up with Delayed Surgical Recovery R/T aftercare neoplasm surgery AEB open draining wounds, pain, feeling weak and tired.
    The ineffective thermoregulation and deficient knowledge sound good too, I'll look more into them.
    Thanks for the help
  5. by   Daytonite
    sorry kiddo, after i responded to your post last evening, i turned off my computer and went to bed.

    as for your idea to use acute pain r/t physical injury agents secondary to melanoma excision aeb patients statements of pain of the upper left back area, let me just point out to you that the information following the "r/t" is always what is causing the nursing diagnosis problem, in this case, the acute pain. so, to double check that you have put all these elements together correctly you need to ask yourself this question: are physical injury agents causing this patient to have acute pain? i understand that the term "physical injury agent" is a broad term and if that is what your instructors want you to use instead of "surgical disruption of tissues" then that is what you have to use. just as a matter of preference, i would change the second part of the related factors to "secondary to excision of melanoma". to me, that just sounds better. but, as i said, that just my own preference. this is your care plan.

    the definition of delayed surgical recovery is as follows: "extension of the number of postoperative days required to initiate and perform activities that maintain life, health, and well-being. defining characteristics include: evidence of interrupted healing of surgical area (e.g., red, indurated, draining, immobilized), loss of appetite with or without nausea, difficulty in moving about, requires help to complete self-care, fatigue, report of pain/discomfort, postpones resumption of work/employment activities, perception that more time is needed to recover. related factors: to be developed ". (nursing diagnoses: definitions & classification 2005-2006 published by nanda international. page 194) if you think your patient fits the parameters of this nursing diagnosis, then use it. however, remember that your r/t items, even though nanda hasn't developed them yet must be the cause of the delay in recovery. so, ask yourself, is aftercare neoplasm surgery causing this patient to have delayed surgical recovery? i'm trying to think of things that will delay recovery. malnutrition, age and wound infection were three that popped into my mind right away. i was just looking at the nursing interventions for this diagnosis in my ackley and ladwig nursing diagnosis handbook trying to get some ideas on this and one of the things that jumped right out at me was patients who have delayed healing times because of their diabetes. elevated blood sugars will screw up healing tissue every time. some of the interventions are repeated at the site i've given you. might kind of back you into some ideas for your r/t item(s) to go with this diagnosis [ex: delayed surgical recovery r/t recent weight loss and inadequate food intake aeb delayed healing of surgical wound].

    wow! you're really getting to be quite the care plan writer! i'm seeing so much improvement in how you are putting things together since your very first post for help with a care plan. keep up the good work!