help with a diagnosis

Daytonite, BSN, RN · Nov 20, 2008

risk for infection related to inadequate primary defense (broken skin) as evidenced by surgical wound on left lower extremity.

you cannot have evidence (signs or symptoms) associated with a "risk for" diagnosis because the problem (an infection) does not even exist yet. even if an infection did exist, a wound is not evidence of an infection. evidence of an infection includes things like elevated wbcs, fevers and inflammatory response (redness, heat, swelling and pain).

risk for delayed surgical recovery related to surgical wound on left lower extremity, secondary to decreased circulation and effects of chronic disease.

this doesn't sound logical. why not say

risk for ineffective tissue perfusion, peripheral r/t impaired circulation

? that's what was going on to begin with. did the surgery correct that problem?

stephynic21 · Nov 22, 2008

risk for infection related to inadequate primary defense (broken skin) as evidenced by surgical wound on left lower extremity.
you cannot have evidence (signs or symptoms) associated with a "risk for" diagnosis because the problem (an infection) does not even exist yet. even if an infection did exist, a wound is not evidence of an infection. evidence of an infection includes things like elevated wbcs, fevers and inflammatory response (redness, heat, swelling and pain).

okay, took your advice on the second and it sounds alot better (thank you!), but i'm still not sure how to word this first one. i do see what you are saying tho....she isn't at risk if i'm saying there is evidence. glad i posted it on here or my teacher would have killed me lol. anyways, every other diagnoses that i'm tossing around in my head doesn't sound good to me. could it be risk for infection related to inadequate primary defense (broken skin), secondary to surgical wound on left lower extremity??? or do i just stop it at broken skin? that doesn't seem right to me either..i feel like i need to include what broken skin i'm talking about in there somewhere. i can work up the rest of the careplan fine but i always have trouble getting the wording right on these lol. any help is always greatly appreciated :heartbeat

Daytonite, BSN, RN · Nov 22, 2008

When you are doing these "Risk for" diagnoses you need to have something in mind that you are aiming at to prevent, but you never actual include the signs or symptoms of it in an AEB statement. It's like having a "silent e" in a word--you never say it. Primarily, with Risk for Infection you are trying to prevent a wound from getting a bacterial infection or an infection in progress from going septic.

So, as best as I can tell is you have a lady who had a reverse saphenous vein graft and you don't want it to get infected, right? The reason it would get infected would be more likely because of her diabetes (tendency for high blood glucoses which provide a great growing medium for bacteria), crappy circulation (she's got PVD which means she doesn't get much oxygen to those tissues and this surgery is a rescue operation for an occluded distal femoral artery and we don't know if it has been totally successful yet or not) and the fact that she had the invasive procedure (a great way for bacteria to have been introduced into the tissues). Do you have any evidence of immunosuppression (low WBC counts)? Even if she is on antibiotics she is isn't out of the woods. I would be inclined to call this Risk for Infection R/T difficultly controlled serum glucose, impaired peripheral circulation and surgical invasion of tissues. You can merely say, Risk for Infection R/T surgical invasion of tissues or Risk for Infection R/T surgical invasion of tissues of left lower extremity.

Your interventions are going to be to prevent an infection, not wound care, per se. You may mention the wound care, but you will focus on maintaining sterile technique because you don't want to introduce bacteria into the wound. You will monitor for signs and symptoms of infection/inflammation (any increase in redness, heat, swelling and pain). Monitor the size and any drainage and its description. Monitor V.S., especially fever. Monitor labs, especially white counts. You will report any increase in WBCs or fevers to the doc. Report any increase in wound size or increase in amount of drainage to the doc. I would measure the circumference of the right and left leg at a specific point daily. If the left leg starts increasing in size I'd notify the doc because this is an increase in swelling, one of the signs of inflammation and infection.

Does that help?