Need help with developing nursing diagnoses & patient outcome

a care plan is a determination of the patient's nursing problems (expressed as nursing diagnoses) and strategies on how to solve them (your nursing interventions). we use the nursing process to help us and it goes like this:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

using the information you posted i can start you off. . .

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - why was the bso done?

• laparoscopic bilateral salpingo-oophorectomy 3 weeks ago
  
• found to have a wound infection at incision site 2 days ago
  
• wound culture shows positive heavy growth of staphylococcus aureus
  
• htn
  
• diabetic
  
• smokes 0.5 pack of cigarette for 40 years

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - when infection occurs, the inflammation response also happens. the inflammation response also happens whenever the body incurs trauma, as when it has been cut into during surgery. the cardinal signs of inflammation are redness, heat (fever), swelling and pain. fever can be elevated or low grade. white count should be elevated. did you check the labs? was her skin flushed? is there a possibility that she might be dehydrated due to the loss of heat as a result of elevated fevers? were her heart and respiratory rates elevated? a complication of infection is sepsis which can lead to shock.

• drainage - needs to be more descriptive, is it purulent?
  
• erythema - what and where is there erythema
  
• pain - where is there pain and how can you rate that objectively?

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

1. impaired tissue integrity r/t surgical intervention aeb drainage from the larger llc incision and surrounding erythema and pain.
   • everything that follows "aeb" is your evidence that the problem (impaired tissue integrity) exists. pain is not evidence of broken skin.
     
   • better (and this is just an idea): impaired skin integrity r/t surgical intervention aeb redness, swelling and serosanguinous purulent drainage from ___ inch (horizontal. vertical, transverse) surgical incision on lower abdomen.

[*]acute pain r/t inflammation in surgical site aeb ???

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem

• i dont know how to put the patient outcome - until you start planning what it is you want to accomplish you won't know what your outcome will be. go back up to that outline i first posted and look at the planning section. your nursing interventions target and treat that aeb evidence and in this patient it is likely to improve it. so, if you have interventions to treat the impaired tissue integrity, which i assume will be things on the order of how to do the dressing changes, then your outcomes will be things that are the positive reflection of that. if your aeb evidence supported the problem of impaired tissue integrity, then that evidence is going to be improved or go back to normal if your interventions are successful. see https://allnurses.com/forums/2509305-post158.html on how to construct a goal statement.

you asked. . .are there nursing diagnosis related to positive staphylococcus aureus?