Need help in medical surgical case study

AJJKRN · May 16, 2015

You'll have to tell all the great minds here what you think first or you may not get any substantial help...just an FYI...

Tilak · May 16, 2015

Mr. Ben Casey is a 34-year-old male who was presented to ED with motor vehicle accident and had a fracture of the left Femur and open fracture of the left Tibia. So ORIF was done for both left tibia and femur. After, 5 weeks post-op he was readmitted via ED with an infected wound (distal left leg) and the tests revealed osteomyelitis of tibia with MRSA in the wound. Surgeons performed a wide excision of the infected area, and applied a VAC dressing.

His initial assessment: Self-report a throbbing pain level of 6/10 in the left lower leg. Left Limb: strong pedal pulse; foot is pink and warm to touch; Capillary refill

Wound: 1.5cm dehiscence left tibial wound; Oozing yellowish/brown, purulent pus; surrounding tissue is red, inflamed and very warm to touch; Moderate swelling around the site.

So what are the actual and potential health problems for this patient? How can you prioritize his health problems and Intended patient outcomes?

Ans: In actual health problems, I think acute pain and infection, whereas osteomyelitis and permanent disabilities as potential health problems. I have given in 1st priority as a pain, because he is having pain in the wound site. And infection can the next priority.

RN403, BSN, RN · May 17, 2015

Just be careful with your nursing diagnosed. Osteomyelitis as you stated above, would be a medical diagnosis and not a nursing diagnosis. You might also add impaired skin integrity as a nursing dx.

Tilak · May 17, 2015

Thank you

nurseprnRN, BSN, RN · May 19, 2015

You are in school to learn to be a nursing diagnostician and treat people for what you diagnose. Yes, you are. You think it's all about learning how to do stuff like injections and IVs and tubes, but those are just tasks. You are learning how assess human responses and prescribe nursing measures.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

As an example: How does a physician make a medical diagnosis of anemia? The physician doesn't go to a list and say, "Gee, this guy looks pale, must be anemic, sounds pretty good to me," right? No- a diagnosis is made by obtaining a CBC. Then how does the physician know what caused it? Ah, then we collect more data-- renal failure (low erythropoietin), marrow malignancy (differential), occult GI beed (stool check), big bleeding with IV replacement (trauma record)... Then the physician can develop a medical plan of care to treat the causative (related-to) factors for the diagnosis made on data.

Nursing diagnosis is the same thing. A nurse can't just pick a diagnosis out of a list. And you can't make a diagnosis without data, either. So... my first suggestion is banishing the words "pick/find/choose" from any discussion of the NANDA-I list of approved nursing diagnoses. I think if students got this concept in their first week of school, that they will learn how to make nursing diagnoses, they'd have a better hook to hang their hat on, so to speak.

This is why you can't say, "My patient has diabetes. What are his nursing diagnoses?" Sure, when I admit somebody with diabetes I have some good ideas about possible nursing diagnoses based on my experience with caring for diabetics in many settings-- like, oh, knowledge deficit, fluid imbalance, impaired CV function, ineffective peripheral issue perfusion, pain, and many other things often seen in diabetics-- but I can't make one of them until I am sure the patient actually has defining characteristics. If I'm a smart person I will also keep my eyes and ears open for other nursing diagnoses for this patient -- maybe I see evidence of abuse, or sexual dysfunction, or death anxiety, or ineffective denial, or powerlessness, or risk for injury, or risk for self-directed violence, or contamination or .... You get the picture. This is why limiting your vision to "nursing diagnosis for diabetes" is so, well, limiting.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." You can thumb through your NANDA-I 2015-2017 and find lots and lots of medical diagnoses as related factors. They are not the origins of nursing diagnoses, however.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and a related/caustive factor. (Exception: see "risk for" diagnoses) (Think of the physician who has to have some lab work to diagnose anemia...same thing.)Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at students.

This is why you can't say, "My patient has diabetes. What are his nursing diagnoses?" Sure, when I admit somebody with diabetes I have some good ideas about possible nursing diagnoses based on my experience with caring for diabetics in many settings-- like, oh, knowledge deficit, fluid imbalance, impaired CV function, ineffective peripheral issue perfusion, pain, and many other things often seen in diabetics-- but I can't make one of them until I am sure the patient actually has defining characteristics. If I'm a smart person I will also keep my eyes and ears open for other nursing diagnoses for this patient -- maybe I see evidence of abuse, or sexual dysfunction, or death anxiety, or ineffective denial, or powerlessness, or risk for injury, or risk for self-directed violence, or contamination or .... You get the picture. This is why limiting your vision to "nursing diagnosis for diabetes" is so, well, limiting.

NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a nursing diagnosis first from a medical one and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk forâ€ diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

"Risk for.. " diagnoses do not have defining characteristics, they have risk factors.

Third:Setting priorities. This sort of assignment is often made not only to see if somebody can recite rote information but to elicit your thought processes and see how well you can defend your reasoning. There is often no single priority; defend yours. Your faculty will be gratified to see you try and make your case.

So, what is the reasoning you have applied to your ranking, as applied to a specific patient or to people in general?

Now, as to your specific question:

Hard to give you much feedback, as you haven't mentioned any nursing plan of care in your study. Can you tell us more about your assessment findings for this patient? Even if he's an imaginary patient, you need more than medical diagnoses to write a nursing plan of care.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.