I'm STUCK, please give me your advice :)

[kmh01]

I am writing a long process for my Med-Surg class. I am having such a hard time coming up with my nursing diagnosis! I need 4, ofcourse prioritizing with interventions and rationales. I am at the end of my second semester. My book only has one small paragraph about my patient's admitting diagnosis, and the care plan books I have don't have anything!

Patient was admitted for scrotal cellulits and a newly diagnosed type II diabetic. He had a surgery for debridement that left 3 open wounds to the groin area. PMH: asthma, obestiy, smoker

here's what I have:

1: Risk for complications (sepsis) r/t open wounds, IV site, anemia secondary to scrotal cellulitis and DMII

2: Ineffective tissue perfusion r/t inflammatory response secondary to cellulits, DMII, obesity, smoker evidence by, hyperglycemia, swollen lymph nodes, and open wounds

3. Activity Intolerance r/t open wounds, medications, obesity, pain secondary to recent surgery evidence by patient stating, "they want me to get up, but I just don't feel like it"

4. Acute Pain r/t open wounds secondary to recent surgery evidence by patient stating pain level being 7/10.

I have been trying all weekend to come up with something, can you please give me some insight! Thank You, Thank You, Thank You. :)

[charli_appleRN]

It sounds like youre stuck on the wounds. What about the newly diagnosed diabetes? Does the pt know all there is to know about that? What part does nutrition play in an obese diabetic with open wounds? What about the smoking with asthma? Did you do an assessment or is this the info you were given?

[kmh01]

I did do an assessment, here's where I am confused. Here's our directions to pick the priority nursing diagnosis...

#1 priority in regards to pathophysiological needs

#2 nursing diagnosis based on what you feel your care was centered around. (which was mainly teaching about wound healing, nutrition, and DMII)

Maybe #1 should be something about imbalanced nutrition? and number two knowledge deficit about newly diagnosed DM, wound healing and nutrition.

Our instructor number one should be the one that could kill our patient... and if that problem is solved then the rest will fall into place..?

[nurseprnRN, BSN, RN]

Your instructor is right. So what does he, himself, have to work on that, if not addressed properly, would put him at greatest, fastest risk of a bad thing happening? If you look at his meds, some of the effects and side effects might give you a clue.

Also, remember that for many patients there is no ONE overarching priority-- it all has to happen. Your faculty has more than a passing interest in finding out what your thought processes are (how you use your critical thinking skills!) when you choose and justify your priorities.

Decide on them based on good reasons, and there you are.

[brillohead, ADN, RN]

I was always told that a "risk for" is not to be used as a "priority" -- you need to use something that they "already have" instead.

First thing that jumps out to me is "impaired skin integrity" -- that covers the wounds without being a "risk for".

I would also think that "deficient knowledge" would be another you could use -- they will need lots of teaching to get their DMII under control, and problems with their blood glucose will slow their healing process.

I recommend buying a few different (older/used/cheap) books -- I love the website BetterWorldBooks.com - New & Used Books for Sale, Textbooks, Book Reviews & more - FREE SHIPPING for this. Get the "clinical handbooks" that accompany med-surg nursing textbooks, and they'll give you all kinds of nursing diagnoses and interventions for various diseases/diagnoses. Here's an example: Manual of Medical-Surgical Nursing Care by Pamela L. Swearingen, Dennis G. Ross - Reviews, Description & more - ISBN#9780323016476 - BetterWorldBooks.com or Clinical Companion to Medical-Surgical Nursing by Shannon Ruff Dirksen, Sharon Mantik Lewis, Margaret McLean Heitkemper - Reviews, Description & more - ISBN#9780323018968 - BetterWorldBooks.com

They also have different careplan/NANDA books there. This way, when you can't find what you need in your "required" textbooks, you have a fighting chance of finding something relevant in your backup books.

[charli_appleRN]

In that case, uncontrolled blood glucose can kill the pt and stop the wounds from healing. But what about the ABC's? Airway and breathing comes first.

[kmh01]

Thank you so much for the responses.... That's why I was thinking Risk for complications of infection (sepsis) r/t open wounds, delayed wound healing secondary to scrotal cellulitis and DMII for #1 and now Knowledge deficit r/t wound healing, nutrition, DMII secondary to scrotal cellulitis, obesity, and newly diagnosed DMII evidence by patient stating "he has no idea about any of this." for #2

Do you think that sounds right????

for #1 because of the location of the wounds, his obesity (not being able to clean them himself), nutrition and DM all play a role in the wound healing... and his lack of knowlege toward cellulitis.

Thank you again :) It's nice to hear some reinforcement... I have been driving my self crazy, since we have not talked about cellulitis at all.... now I"m realizing I need to just look at it as an infection and what could happen....

[kmh01]

we were told in 1st semester that a "risk for" could not be number one.... now (2nd semester) they are saying if the "risk" is an issue and it could kill them, then it could be number one...

so maybe number one should be "impaired tissue integrity r/t open wounds evidence by surgical debridement"

That sounds more like a pathophysicological need.... than "risk for sepsis"

[nurseprnRN, BSN, RN]

If your nursing diagnosis doesn't restate to "I think my patient has this... (nsg dx). I know this because I have seen (as evidenced by), and he has those things because he has (related to)" then it's not accurate.

So.. "I think my pt has impaired tissue integrity because I see that (AEB) he has open wounds caused by (r/t) surgical debridement," not the other way around. (He doesn't have impaired integrity because he has surgical debridement caused by open wounds.) Make sense?

In the classic listing, it would be "Impaired tissue integrity r/t surgical debridement AEB open wounds."

I don't know why schools don't teach plain English.

[DawnJ]

"If your nursing diagnosis doesn't restate to "I think my patient has this... (nsg dx). I know this because I have seen (as evidenced by), and he has those things because he has (related to)" then it's not accurate."

I love this! We are just starting the whole nursing diagnosis can of worms, and this really clarifies it for me. Thanks