Nursing Diagnosis for Care Plan

[Vangoh]

:) Today I took care of a 72 year male caucasian. This patient is in a long term care facility and is there for a non-healing surgical wound to the lower left leg with necrosis to the muscle. I've discussed with my instructor my two possible nursing diagnosis. Can someone please respond on whether or not these are appropriate; especially from a students point of view. Also the pt. has lost approx. 100 #'s in the last 3 months. Thanks for yalls help.

#1- Risk for infection r/t ???

#2- Nutrition: altered, less than body requirements

Thanks,

Vangoh

[PSA, RN]

How about this one.

Risk for infection r/t inadequate immune system.

[PSA, RN]

One other one:

Impaired tissue integrity r/t open wound

Hope those help...

[Vangoh]

Thank you, I just wasn't sure what it was related to because he's got so many other illnesses such as Coranary Artery Disease, Peripheral Vascular Disease, Hypertension, Renal Failure and pt. also contracted West Nile Virus after receiving a blood transfusion. The care plan has to be on his non-healing surgical wound. Thanks again.

[PSA, RN]

I have a complete care plan on infection and tissue integrity in my old ncp's but I need to go look for them. If you are going to be on the computer a while I can go and try and find them and post one later on. I have been out of school a while so I need to go and dig them out.

You can also look at the pain ncp that I posted on that other thread.

Just let me know and if you want I can send those later.

Take care,

[NancyRN]

"Altered Tissue Perfusion" or "Impaired Tissue Integrity" . Related to decreased blood and nutrients to tissues, secondary to: surgical wound.

[Vangoh]

Thanks you guys I really appreaciate it. I can use all the help I can get. I'll be here as long as it takes, thanks. I appreciate it very much. For some reason this one is giving me a brain fart, maybe its because I'm burnt out, I've already done enough care plans last semester and this one, I just can't think today, I guess; sorry for the inconvenience.

God Bless!

[PSA, RN]

Well, here is one I found so far:

Risk for infection r/t inadequate immune system secondary to surgery.

Short term goal: the patient will remain infection free AEB absence of redness, swelling, and discharge at surgical site. Temperature will also remain below 100.

Interventions:

1. Observe and report signs of infection such as redness, warmth, and discharge.

2. Assess skin for color, moisture, texture, and turgor (elasticity).

3. Encourage fluid intake.

4. Observe and report if client has a low-grade temperature or new onset of confusion.

5. Encourage adequate rest to bolster the immune system.

I also have rationales for these interventions too if you need them.

Take care,

[Vangoh]

Yes Pamela, the rationales would be great!! You are a life saver. Thanks again. Take care as well.

[PSA, RN]

Rationales:

1. With the onset of infection the immune system is activated and signs of infection appear.

2. Intact skin is nature's first line of defense against microorganisms entering the body.

3. Fluid intake helps thin secretions and replace fluid lost during fever.

4. Fever or sudden confusion is usually the first and often the only sign of infection in the elderly.

5. Chronic disease and physical and emotional stress increase the client's need for rest.

Hope this helps.

[Vangoh]

Thank you so much Pamela! I really do appreciate everything. I hope someday I can help. God Bless!!

Vangoh