HELP with Nsg Diagnosis/Care Plan - gunshot wound

[RLynn39]

Arg! Here I am again. 'Been doing alright with these care plans, but my most recent patient is throwing me for a loop! I need to come up with *only* the top two nursing diagnoses, including interventions and outcomes.

My patient is s/p rotational flap for a comminuted tib-fib fracture resulting from a gunshot wound. He was initially treated with intramedullary rod/nail fixation, I&D's with wound v.a.c., and now the flap. The gunshot injury occured in August, and the patient has since suffered from chronic impaired wound healing, inluding wound infection. He has had antibiotics infusing via PICC line for over two weeks.

I've come up with the following diagnoses:

1. Acute pain r/t invasive surgical procedure aeb patient's verbal report of 8/10 on numeric pain scale and guarding behavior.

2. Risk for Infection: risk factors include tissue destruction and increased environmental exposure, and decreased hemoglobin.

3. Impaired physical mobility r/t pain, surgical procedure, and loss of integrity of bone structures aeb inability to bear weight.

4. Delayed surgical recovery r/t extensive surgical procedure, postoperative surgical site infection aeb difficulty in moving about,

5. Ineffective coping r/t use of substances to cope with life events as evidenced by verbalization of feelings of helplessness and dependence on drugs and alcohol to alleviate stress.

I'm having trouble coming up with the two most important/priority diagnoses. Thoughts??? Anyone??? My inclination is to go with pain and impaired physical mobility. Risk for infection doesn't seem appropriate, as he is on antibiotics. Delayed surgical recovery relates mostly to his history, right? Ineffective coping seems extremely important to address, but I have no idea what the interventions/outcomes would be.

Thanks to any and all for imput!

Happy Saturday night!

Robbie

[Daytonite, BSN, RN]

delayed surgical recovery ([color=#3366ff]delayed surgical recovery) has to do with not only delayed wound healing, but self-care deficits and inability to perform adls as a result. it definitely applies to this patient. did i pick up a hint of this patient overusing pain medication to cope with his situation? that might be the second diagnosis. otherwise, i would use risk for infection (sepsis related to the presence of the picc line and compromised immune system--he is already getting atbs for the wound infection) ([color=#3366ff]risk for infection)

[RLynn39]

delayed surgical recovery ([color=#3366ff]delayed surgical recovery) has to do with not only delayed wound healing, but self-care deficits and inability to perform adls as a result. it definitely applies to this patient. did i pick up a hint of this patient overusing pain medication to cope with his situation? that might be the second diagnosis. otherwise, i would use risk for infection (sepsis related to the presence of the picc line and compromised immune system--he is already getting atbs for the wound infection) ([color=#3366ff]risk for infection)

hmmmm....would those be the two most important? can you explain to me why?

no, he isn't using pain meds to cope. the gunshot wound and subsequent surgeries have caused him a great deal of stress regarding his inability to work and meeting bills. outside the hospital, he is using street drugs and alcohol to cope with this stress.

my preceptor always argues that psychosocial issues are of the greatest concern. but, i am not sure if that applies here.

thanks for the brainstorming

[Daytonite, BSN, RN]

This is your patient who you saw and took care of. I was only responding to what you posted. The construction of your diagnostic statements had some technical faults. Those are easily corrected. I won't make decisions about the assessment and which two problems of the five poses the greater need for attention to the patient. That has to be up to you.

[RLynn39]

This is your patient who you saw and took care of. I was only responding to what you posted. The construction of your diagnostic statements had some technical faults. Those are easily corrected. I won't make decisions about the assessment and which two problems of the five poses the greater need for attention to the patient. That has to be up to you.

Ah. I see. I thought you were saying those were the two most vital. I also thought I had read somewhere that there was a hierarchy method of determining priority diagnosis.

Am I wording the coping one correctly?

Tnx!

[Daytonite, BSN, RN]

ineffective coping r/t use of substances to cope with life events as evidenced by verbalization of feelings of helplessness and dependence on drugs and alcohol to alleviate stress.

the "use of substances" is evidence of ineffective coping not the cause of it. the cause of the ineffective coping is the inability to use effective coping strategies, never having learned them or developmental lags. the related factors for this diagnosis are listed on this web page:

[color=#3366ff]ineffective coping

. the related factor is

why he does the drugs and feels bad about it

. it's probably more like

ineffective coping r/t situational crisis aeb abuse of street drugs and verbalization of feelings of helplessness and dependence on drugs and alcohol to alleviate stress

. i'm just guessing that it's because of the situation he is in. drugs are what drug abusers turn to in a crisis.

i prioritize diagnoses by maslow's hierarchy of needs: http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs. by that strategy, your 2 top diagnoses of the 5 you originally proposed are (1) delayed surgical recovery and (2) impaired physical mobility. the remainder fall in priority like this: (3) acute pain (4) ineffective coping (5) risk for infection.