Help PLZ! Nursing DX for neck abscess?

[strugglingstudent87]

she had it drained 2 days ago...so i guess she is just recovering thats why she's still in the hospital. she has hx of non-hodgkins lymphoma (currently in remission), dementia..and some other things. My instructor wants us to do challenging nursing dx's but...all i can think of is impaired skin integrity, & acute pain....

i am really bad at these....will it ever get better?! lol

[kalley]

I am just gonna throw some out there, since I am taking a break from studying these anyway... Chronic Confusion, Risk for Situational Low Self Esteem, Risk for Infection.

How about adding one about her mental ability or coping skills based on your interactions with her. Sorry I can't be of more help. We just started these last week and are having a quiz on them tomorrow. Good luck with your care plan.

[Inkits]

So I pulled out the ND handbook and here is what I found...

Impaired TISSUE integrity r/t altered circulation,nurtritional feficit or excess

Ineffective HEALTH maintenance r/t deficient knowledge regarding self-care with abscess

Ineffective PROTECTION r/t inadequate nutrition, abnormal blood profile, drug therapy,, depressed immune function

Distrurbed BODY image r/t dysfunctional open wound

Imbalanced NUTRITION: less than body requirements r/t biological factors or infection

Impaired TISSUE integrity r/t woulnd presence of infection

Now if you need any more ideas let me know I have gotten really good using this book and looking for alternative DX. We have had to use this all through school and always have to have the r/t with the DX.

Hope this helps.

Angie:clown:

[Daytonite, BSN, RN]

see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. a care plan is all about determining what the patient's nursing problems are. these are dependent on what your initial assessment of the patient is. assessment involves collecting the following information:

• a health history (review of systems) - neck abscess, hx of non-hodgkins lymphoma (currently in remission), dementia..and some other things?
  
• performing a physical exam - no data provided
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no information provided
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - no signs and symptoms regarding this abscess have been provided
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - no information provided
  

the patient is being kept in the hospital for one of three reasons that i can think of: (1) to receive iv antibiotics for the abscess, (2) skilled nursing as medicare defines it for the care of the abscess, or (3) they are planning to send the patient into skilled care at a nursing home and this requires a 3-day hospital stay first.

no assessment data to support the diagnosis of acute pain has been provided. there must always be evidence (symptoms) to support each nursing diagnosis you choose. assessment and description of pain includes the following:

• where the pain is located
  
• how long it lasts
  
• how often it occurs
  
• a description of it (sharp, dull, stabbing, aching, burning, throbbing)
  
  • have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
    

  [*]what triggers the pain

  [*]what relieves the pain

  [*]observe their physical responses

  • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
    
  • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
    
  • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness