NCP, Laboratory test implications,,

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i have a patient who is male,35 years old... slightly obese, has diabetes mellitus...

his CC is intolerable pain.. its due to a 2inches long and half inch deep wound... upon observation pus formation was noted...

he had and on and off fever for two days... vital signs are as follows T- 37.8 degrees celsius, PR-102 RR-26 BP-130/90 mmHg..

on his urinalysis, WBC-25/hpf, RBC-3/hpf, glucose-+++

on his CBC, RBC-3.4million/ul, HGB 10g/dl, HCT-46%,wbc-20,000mm3

my problem is i dont know what could be my nursing diagnostics... im thinking either injury,risk for or Infection,rick for?

any other options on diagnostics will be helpful and possible can i see a sample NCP?(maybe a link or so)

on laboratory..High WBC counts are signs of infection right? and positive glucose count is because of his diabetes...

what about the RBC on urinalysis(what does it imply)?

and howcome on his CBC, the RBC and HGB implies on anemia? hematocrit is normal right?

sorry fir lots of questions.... im new at this stuff...(student):o

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he si febrile(mildly), wbc elevated. hgb low thus the anemia. elevated wbc in urine indicates a urinary tract infection or inflammation of the urinary tract. need a urine culture. rbc in urine is a sign of renal damage. the crit on the cbc is good. the diagnosis i would use is potential for bleeding due to anemia. i woulnd use the potenetial or risk for infection b/c he already has one. use this link to do your care plan and to see your diag. http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=32

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he si febrile(mildly), wbc elevated. hgb low thus the anemia. elevated wbc in urine indicates a urinary tract infection or inflammation of the urinary tract. need a urine culture. rbc in urine is a sign of renal damage. the crit on the cbc is good. the diagnosis i would use is potential for bleeding due to anemia. i woulnd use the potenetial or risk for infection b/c he already has one. use this link to do your care plan and to see your diag. http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=32

:up:thank you for the clarification(i was using anemia as risk/implication) but im not sure how it fits..... can you explain me more if there's a relation on anemia,diabetes mellitus, and his infected wound...

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the dm will cause it to take longer for the wound to heal. thus you can use potential for delayed healing r/t dm. the anemia means that he also has the potential for decrase nutrient and or o2 carrying capicity due to low hgb. thus imparing healing. you could also use risk for pain intolerance r/t wound infection or something along those lines. you have to adress the pain aspect of it

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"Infection, Potential for bleeding due to anemia"

or

"acute pain related to infection of wound on the right foot"

is this right?

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acute pain related to infection of wound on the right foot is the one i would go with

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Specializes in Cardiac Telemetry, ED.

He's septic. What is the most life threatening thing that could happen? That would guide me in choosing my priority nursing diagnosis.

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He's septic. What is the most life threatening thing that could happen? That would guide me in choosing my priority nursing diagnosis.

and what would that be?

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Specializes in Cardiac Telemetry, ED.

Sorry, you need to do your homework for yourself!

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Sorry, you need to do your homework for yourself!

lol thats why im researching... i just cant possibly put the right terms right...(and possibly i don't know the correct term)

thanks anyways..

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He's septic. What is the most life threatening thing that could happen? That would guide me in choosing my priority nursing diagnosis.

you cannot diagnose the patient. sepsis is a medical diagnosis. and yes the pt does meet the criteria. but i doubt that his instructors would expect him to know that at this point. from what i am seeing i would assume that this is a 1st or second semester nursing student? were you able to identify sepsis then? if you were good for you. but most nursing students dont get that till critical care later in their studies.

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Specializes in Cardiac Telemetry, ED.
you cannot diagnose the patient. sepsis is a medical diagnosis. and yes the pt does meet the criteria. but i doubt that his instructors would expect him to know that at this point. from what i am seeing i would assume that this is a 1st or second semester nursing student? were you able to identify sepsis then? if you were good for you. but most nursing students dont get that till critical care later in their studies.

I'm well aware of what constitutes a medical diagnosis vs. a nursing diagnosis, and no, I don't expect a new student to be able to recognize sepsis. However, a resourceful student can easily find information pertaining to sepsis and nursing diagnoses if they know how to use a search engine. Have you ever heard the term "hint"?

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