help with priority nursing dx

[nursemom63]

I'm figuring out my first nursing dx (and prioritizing) on a patient scenario. The patient (developmentally delayed) has an infection to a deep cut on his foot because he didn't clean wound or change dressings after being sent home from ER 3 days earlier. He wouldn't let his mom do it either because it hurt. He is taking the antibiotics though, "just like the nurse said". Anyway, I know Infection is not a nursing diagnosis - but the wound is clearly infected (purulent drainage, redness, edema). So I'm unsure about what the priority dx would be...it seems odd to say "Risk for Infection" when it's already infected. Acute pain is another - which the patient verbalizes. But the pain will obviously resolve if the infection is cleared. (He will let the nurse change the dressing.) I just want to make sure I'm on the right track. I think spread of infection trumps pain regardless of what the patient thinks (and he's developmentally delayed - like a kid who doesn't want an immunization - but he does want to get better because he is taking the antibiotics). So can I write "Risk for further infection"? Or do I assume the Dr will treat that (dr ordered labs based on nurse assessment of wound) and I, as a nurse, have a priority of tending to his pain, educating about wound care, etc...?

[tarheelsu]

I would look at impaired skin integrity and acute pain.

You can't do risk for infection b/c a risk diagnosis can only been used when risk factors are present, but not when the condition is actually present. Risk for further infection is not a NANDA.

You could look into knowledge deficit (wound care) but I don't think that would be his priority dx.

[MrsMig, BSN, RN]

I would look at impaired skin integrity and acute pain.

You can't do risk for infection b/c a risk diagnosis can only been used when risk factors are present, but not when the condition is actually present. Risk for further infection is not a NANDA.

You could look into knowledge deficit (wound care) but I don't think that would be his priority dx.

I agree - I would have selected the same as the PP.

Acute Pain

Impaired skin integrity

Knowledge deficit

That's how I'd prioritize - GL

[nursemom63]

thanks for both of your input...I'm just having a difficult time rationalizing the whole thing...according to Maslow's hierarchy, pain (comfort) takes precedence...but I keep thinking, pain won't kill my patient, but spread of infection could lead to sepsis and that could...so I still come back to the infection problem...maybe I'm not thinking like a nurse yet? should I assume the dr will take care of the infection? it's really a collaborative problem, but I think my teacher won't go for that...ultimately, the patient's priority would be for the wound to get better (if infection gone = no pain) and the way to do that would be for the nurse to change dressing daily (since he won't and he won't let his mom)...again, my challenge is what takes priority...I can come up with plenty of relevant dx, I just can't seem to prioritize because of the infection and I seem to be overthinking the possibilities

[MrsMig, BSN, RN]

thanks for both of your input...I'm just having a difficult time rationalizing the whole thing...according to Maslow's hierarchy, pain (comfort) takes precedence...but I keep thinking, pain won't kill my patient, but spread of infection could lead to sepsis and that could...so I still come back to the infection problem...maybe I'm not thinking like a nurse yet? should I assume the dr will take care of the infection? it's really a collaborative problem, but I think my teacher won't go for that...ultimately, the patient's priority would be for the wound to get better (if infection gone = no pain) and the way to do that would be for the nurse to change dressing daily (since he won't and he won't let his mom)...again, my challenge is what takes priority...I can come up with plenty of relevant dx, I just can't seem to prioritize because of the infection and I seem to be overthinking the possibilities

Try to think of it this way....

when you walk into the patient's room and he's complaining of pain and has a wound w/an infection. What's the priority and what can you address and rectify the quickest? Pain...administer pain meds (as prescribed) or comfort measures. It's common to administer pain meds prior to a task - i.e. ambulation or changing of dressings so that the patient is relaxed and not exasperating the situation with add'l complications - i.e. increase BP, hyperventilation, or increased anxiety - the list could go on. Keep in mind the patient will not be compliant or be open to teaching w/o comfort measures. Trust me, you are not changing a dressings w/o pain meds administered! Also, don't "assume" anything about the Dr. addressing the infection as they only prescribe and nurses carry out their orders. This is where you need to check the Dr. orders and see what they have prescribed and follow their script of treatment and/or medication administration. Obviously if there is no order, this is where you'd contact the Dr.'s office....

Does this help?

[nursemom63]

thanks so much...actually, I did finally come to conclusion that pain needs to be addressed before tending to changing dressings and preventing spread of infection...but I was still second guessing myself, so your post really puts my mind at ease in knowing that I'm on the right path!