Need help with developing nursing diagnoses & patient outcome

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my patient (58 y/o female) had laparoscopic bilateral salpingo-oophorectomy around 3 weeks ago. she went to clinic for post-op exam two days ago and found wound infection at incision site. there was drainage/erythema and pain. (pain is now under controlled). they did a culture, and found there was positive heavy growth of staphylococcus aureus. patient have htn, is diabetic, and have been smoking 0.5 pack of cigarrete for 40 years.

so far i have impaired tissue integrity r/t surgical intervention aeb drainage from the larger llc incision and surrounding erythema and pain.

but i dont know how to put the patient outcome, can i say control wound infection site? (size does not increase).

are there nursing diagnosis related to positive staphylococcus aureus?

what other diagnosis can i make..

its my 2nd time in clinical.. i'm still pretty lost on how to do the care plan =(

please help me!! :cry:

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Infection control is important for this pt. How would you prevent spreading her infection to others, and prevent her from being infected further by others?

Would she have increased nutritional needs r/t wound healing and fighting infection?

You say her pain is under control- how do you know? Would you assess her for pain? How often? How would you make sure her pain stays under control?

If you have to do dressing changes, they could be painful. what preventive measures could you take?

What effect could the infection have on this pt's blood sugar?

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Also, pt outcome is related to your goal- what would your goal be for a pt who has an infection?

Would it be to be free of infection?

How would you know if the infection was cured?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

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.

[*]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.

[*]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?

nursing diagnoses are based upon the patient's responses to what is happening to them. your patient's response to
staphylococcus aureus
was to develop a wound infection and that was a medical determination which we can't use. we have to rely on the signs and symptoms (patient response) that we observe or found in the medical record and go from that. what you observed was the patient had drainage, erythema and pain of the surgical wound. that is what you work with.

diagnosing is the result of logical problem determination. you must systematically break down information you obtain from the patient's medical history, physical examination, and laboratory tests and reassemble it into patterns that fit well-defined groupings of symptoms that describe nursing diagnoses. you use your knowledge of the person's diseases and their treatment, the nursing process and a nursing diagnosis reference to help you.

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thanks!!! it was really helpful!!

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