Help with differentiating nursing diagnoses for careplan

[WayneStateKatie]

I have a HUGE careplan due on Monday. I've gathered all my info done all the background research on my patho, and I"ve got all the basic assessment and situational stuff out of the way. I've been going through my careplanning books and I need to have 3 nursing diagnoses (1 must be a psychosocial). The problem I"m having is all my data from this patient seems to lead me to dianoses that I feel are really... overlapping.. for lack of a better word. I have to do a write up with interventions yada yada yada the usual on the top 2 diagnoses.

I'll give a little info on the pt and the diagnoses I'm thinking about for my pt below. If anyone could look at them and give me some help on how to make them not so overlapping-- or reassure me that it's not really a problem if they do-- that would be great. Thanks in advance!

34 yo obese, white male, presented with abdominal pain. Ultimate diagnosis necrotizing pancreatitis. Had chole performed. History of ETOH abuse, 14 pack year hx, recent diagnosis of DM. MRSA in abdominal wound, stage II pressure ulcer on sacrum. EXCEEDINGLY non complaint. Pt has been in the hospital for 2+ months. Refuses to get OOBTC as ordered or participate in treatment. Has ileostomy and refuses to empty it himself and always makes someone else do it even though he knows how and is capable. There's more but that should be enough for you to be able to read these.....

1. Innefective health maintenance r/t lack of motivation and lack of education and readiness AEB excessive alcohol abuse and stated intention to keep drinking, 14 pack year history with stated intention to resume smoking upon discharge, obesity (BMI 36), non compliance in prescribed physical regimen resulting in stage II pressure ulcer on sacrum.

2. Non compliance r/t barriers to comprehension secondary to motivation AEB unwillingness to participate in prescribed treatment course of getting OOBTC three times a day, unwillingness to care for and change own ileostomy despite having knowledge, refusal to adhere to regimen of incentive spirometry, refusal to adhere to SCD use in bed, development of impaired skin integrity.

3. Impaired skin integrity r/t the effects of pressure and immobility secondary to motivation AEB disruption of epidural and dermal tissue of sacrum.

Please help. The first two basically seem the same to me....... Also would you consider the way I currently listed them as the correct priority? Any suggestion or possible other diagnoses that may be better are appreciated. This is the largest section of my grade and I would like to do well Thanks again!

[Daytonite, BSN, RN]

it's true. your first 2 diagnoses are the same. ineffective health maintenance is used in place of noncompliance. use either one or the other. i would not label him as noncompliant because he is in the hospital and that is submission to medical care. he's just sitting back and letting the staff do everything.

ineffective health maintenance r/t lack of motivation and lack of education and readiness aeb excessive alcohol abuse and stated intention to keep drinking, 14 pack year history with stated intention to resume smoking upon discharge, obesity (bmi 36), non compliance in prescribed physical regimen resulting in stage ii pressure ulcer on sacrum.

• your related factors are ok
  
  
• i wouldn't use the word "noncompliance"
  
  
• i would list this second after the
  impaired skin integrity
  .
  
  
• if he has an alcohol abuse problem diagnose for that just as you are diagnosing the
  impaired skin integrity.
  depending on his assessment there are a number of ways to go with this:
  ineffective denial, impaired nutrition, deficient knowledge, risk for injury
  , etc.