1)"Pain related to infection of wound on the right foot"
2)"Infection related to impaired skin integrity as evidenced by pus:"
3)knowledge in woundcare. "Deficit Knowledge"
4)Knowledge in illness. "deficit knowledge"
are this right?
i dont have any nanda book yet..
please help me... i have until tonight to finish my work...
You need to get a Nanda book. They are your bible for this sort of work. Lots of people also recommend care plan books, but after your 3rd or 4th clinical you may not need it (the care plan book) anymore, so try to find one used. Go get your Nanda book TODAY. Whichever one your school recommends.
1) Pain is classified as aute or chronic, acute being 6 mnths. Pain is measured through a pain scale (1-10) or with a non-verbal patient, through behaviors (grimacing, guarding, crying out). That would be your manifested by (the scale or behaviors).
2) You never use a nursing diagnosis as your "related to". Your "related to" is your factors that contributed to causing the diagnosis. The correct terminology wound be :
"Impaired skin integrity related to (what caused the wound?) as manifested by ..."
3) See 4
4) Should be Deficient knowledge, but what is your assessment findings that support this diagnosis?
Other things, I've never seen a laboratory value for glucose as +++. We all have glucose in our system. Values of between 70-110 are normal. I wouldn't even know how many + you need before it became abnormal and if there weren't any +s, can we assume hypoglycemia? This is incredibly nit-picky, but usually wounds, even here in the states, are measured in centimeters.
Daytonite will be along shortly I'm sure, but in the meantime you should look up her posts and see her breakdown on how to turn an assessment into a careplan.
Your nursing diagnosis will consist of the Nanda diagnosis (the problem you have identified through your assessment), the related to (the contributing factors that caused the problem, you aren't suposed to use a medical diagnosis here, you can use a medical diagnosis for secondary to, also shouldn't use another nusing diagnosis as the related to), secondary to (usually a medical diagnosis), as evidenced by (your assessment findings that support the diagnosis).
IE: Impaired tissue integrity related to (what caused the wound?) secondary to infection as evidenced by wound of (size) with pus on the (where is the wound?).
You prioritize your diagnosis based on the ABCs (airway, breathing, circulation) then Mazlows hierarchy of needs (look it up). I was taught to prioritize "Risk for" below actuals, and honestly, your patient has enough actuals to not even need risk fors.
Specializes in med/surg, telemetry, IV therapy, mgmt.
please make a note that i hang out on the nursing student assistance forum and i do not go looking for student questions on other forums of allnurses. if you do not post your question here on this forum or unless one of the moderators finds your thread and moves it here i am not likely to find it. i also am an old lady and tend to work on the computer in the morning, so post early.
the process of diagnosing involves using the nursing process which is a five step process. diagnosing is not intuitive. it involves scientific principles and critical thinking. for diagnosing, the first two steps of the nursing process are employed. if you fail to be thorough in performing step #1 (assessment) your identification of the nursing problems (diagnosis) also fails. let me show you how to make this process work for you.
step 1 assessment - during assessment you collect as much data from as many different sources as you can before moving on. the patient is not the only source of data, although it is their situation that directs your efforts. assessment consists of:
a health history (review of systems) - a male, 35 years old admitted with a chief complaint of intolerable pain due to a 2 and a half inch deep wound. he has diabetes mellitus and is obese. how did this wound come about? was it a traumatic injury or a result of a circulation problem? that is important information to know. how long has the patient been a diabetic? which type of diabetes does he have, type i or type ii? are there any complications of the diabetes (heart, renal, vision, gi problems)?
performing a physical exam - all you have posted is that he has a 2 and a half inch deep wound in which pus formation was noted, and on and off fever for two days (none of the fevers are listed), his fever on the day you cared for him was 37.8 c (100.0 f), pulse 102 (regular? irregular?), respirations 26 (labored? regular?) and a blood pressure of 130/90. i didn't see a lung assessment, abdominal assessment, assessment of the extremities. does he have pedal or leg edema? where was this wound located anyway? in your last post to this thread you mention something about a wound in the right foot. is that the wound? if it is on the bottom of his foot how does he walk and get around because just visualizing that makes me hurt! much of this information is needed for the etiology of your diagnostic statements. since he had pain in this wound, where is the pain assessment? pain assessment includes:
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
parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
[*]assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - can't help but wonder how being hospitalized has affected his ability to ambulate and accomplish his adls. you have addressed none of these.
[*]reviewing the pathophysiology, signs and symptoms and complications of their medical condition - there are several things you need to know the pathophysiology of in order to know what etiologies you will need to put together with your nursing diagnostic statements: diabetes mellitus and its complications, obesity, tissue damage and the process of inflammation. here are some weblinks that will be of help:
i gave you websites to look up lab data on another thread you started
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - none listed
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - only things listed are
pain (needs more specific description)
2 and a half inch deep wound (right foot?)
pus in wound
on and off fever for two days
t - 37.8 c
pulse 102
respirations 26
b/p 130/90
urinalysis: wbc-25/hpf, rbc-3/hpf, glucose 3+ (blood and whote cells in urine are not uncommon)
cbc: rbc-3.4million/ul, hgb 10, wbc-20,000
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - there are several places to find nanda information if you do not have a diagnosis reference. the taxonomy information is in the appendix of taber's cyclopedic medical dictionary. and the taxonomy for about 80 of the most commonly used diagnoses can be found between these two online websites along with nursing interventions: http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/ and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm. based on the data above, i can come up with the following nursing diagnoses, in priority order by maslow's hierarchy of needs:
hyperthermia r/t inflammatory response aeb on and off fevers for two days, current temperature of 37.8 c, pulse of 102, respirations of 26 and wbc of 20,000
acute pain r/t (what injured the body part that is in pain) and inflammation aeb pain in right foot
impaired tissue integrity r/t (trauma? altered circulation?) aeb a 2 and a half inch deep wound of the right foot with pus
ineffective protection r/t abnormal blood profiles aeb rbc of 3.4million/ul and hgb 10 [this is anemia, however, you have no medical diagnosis of it nor any physical signs and symptoms of it. could be related to oncoming renal failure which would be a complication of the diabetes.]
risk for infection r/t glycosuria and wbcs in urine
your 3-part nursing diagnostic statements should be like a snap shot of the patient for anyone who comes along and reads them. they should tell what each nursing problem is, how it has happened and what the evidence is that identifies this problem. if i walk into the room of this patient i should be able to see or ask about these signs or symptoms and see that the diagnosis was, indeed, made correctly. does that make sense? do you see how the data that was collected contributes to this determination of these problems?
the next step of the process is to develop the nursing interventions. they are based upon the aeb items listed for each of the diagnoses. that is step #3 planning (write measurable goals/outcomes and nursing interventions).
- - - - - - - - - - - - - - -
i want to address the questions you had as well as the nursing diagnostic suggestions you came up with. . .
on laboratory..high wbc counts are signs of infection right? and positive glucose count is because of his diabetes...
on a urinalysis it is not uncommon for there to be wbcs in the urine. when they are present, the lab should do a more specific analysis on them, but they didn't so just a wbc count should not be taken as a meaning of anything. a positive glucose count (the 3+) is glucosuria. it means the kidney has reached the threshold and the blood sugar is elevated. a serum blood sugar should be checked or matched to a finger stick to see a more accurate result of what is going on. when infection is present or the person with diabetes is healing the blood sugars tend to get out of whack.
what about the rbc on urinalysis(what does it imply)?
anemia. remember above i told you to check out diabetes and its complications. renal failure is one of the complications of diabetes. anemia is a complication of renal disease. for all we know, the patient could have had a hemorrhage as well.
and how come on his cbc, the rbc and hgb implies on anemia? hematocrit is normal right?
don't know.
risk for injury
what leads you to believe he is at a risk for injury? based on what you posted, i could not come to that conclusion.
risk for infection
this i could conclude because he already has the elevated wbcs and he has the elevated glucose which would contribute to it.
since i cant choose which diagnoses are to be used.. i figured out ill just do them all..
1)"pain related to infection of wound on the right foot"
2)"infection related to impaired skin integrity as evidenced by pus:"
3)knowledge in wound care. "deficit knowledge"
4)knowledge in illness. "deficit knowledge"
as i said at the very beginning, diagnosing is not about intuition. you must have evidence to rationally prove the existence of every problem you diagnose the patient with. i can tell that your frustration level has gone way up.
pain related to infection of wound on the right foot
pain
is not an official nanda diagnosis. it is either
acute pain
(present less than 6 months) or
chronic pain
(present longer than 6 months). the related factor must be the cause of injury to create the pain.
infection
can't be used because it is a medical diagnosis. you can however, use "inflammation" which is the process that occurs along with infection and is doing the actual damage to the tissue. you also have not included the evidence of the patient's pain. i gave you extensive assessment information for evaluating pain in someone.
infection related to impaired skin integrity as evidenced by pus
there is no such nanda diagnosis.
infection
is a medical diagnosis and your instructors will probably ding you for using this. you can't use another nursing diagnosis (
impaired skin integrity
) as a related factor. just diagnose
impaired skin integrity
as the problem.
knowledge in wound care. "deficit knowledge
not being mean here, but what is this? the proper diagnosis properly written would be
deficient knowledge, wound care r/t ?? aeb ??
. what is the reason (etiology) for this deficient knowledge? i saw nothing that you posted to indicate the patient has any knowledge deficit. what evidence do you have that this man lacks any knowledge of how to care for his wound?
knowledge in illness. "deficit knowledge
same as above. i would combine the two subjects into one diagnosis:
deficient knowledge, diabetes and wound care r/t ?? aeb ??
or
deficient knowledge, disease and wound care r/t ?? aeb ??
good luck with this care plan. i hope you complete it by this evening.
i passed my work.. (although i screw a bit w/ my NCP coz of wrong nursing diagnosis) the case study itself is good for a beginner though..
*but after passing my ncp... we discussed on what problems should we prioritize..
all of my classmates insisted that we should prioritize pain coz its the clients cc..(i answered differently, saying the infection is life threatening than the pain)
and our instructor seems to agree (he reasons out that the infection will take longer to afflict on the patient and the client needs relief immediately)
so what do you think?
(btw the the patient was wounded due to a broken glass, he has DM. he used first aid and pain relievers for 3 days and when he cannot tolerate the pain anymore he went to the hospital)
Specializes in med/surg, telemetry, IV therapy, mgmt.
since you provided more information i can amend the nursing diagnoses i suggested a bit. however, i wouldn't change the order of their priority. you never established that this patient actually had an infection, at least not by the doctor. we nurses have to treat the symptoms. the only symptoms you provided of infection were an elevated wbc count and the presence of pus. the temperature, according to maslow, needs to be attended to first, then the pain. the actual broken skin is a safety issue. the risk for infection diagnosis is for prevention of the infection becoming septic.
hyperthermia r/t inflammatory response aeb on and off fevers for two days, current temperature of 37.8 c, pulse of 102, respirations of 26 and wbc of 20,000
acute pain r/ttraumaand inflammation aeb pain in right foot
impaired tissue integrity r/t traumaaeb a 2 and a half inch deep wound of the right foot with pus
ineffective protection r/t abnormal blood profiles aeb rbc of 3.4million/ul and hgb 10
risk for infection r/t glycosuria and wbcs in urine
for your next care plan please post as much data as you can as far ahead of your due date on the nursing student assistance forum where i can find it, post my suggests and we can discuss them.
drew9319
38 Posts
try nursingcrib.com they have searchabel careplan samples. for nada, nic and noc..you'll have to buy the books