Nursing Diagnosis Prioritizing

[ChristineWV]

Hello,

I am a 2nd yr. Nursing student and have not struggled with care plans or prioritizing diagnoses until this patient. I am stumped and hoping that somebody with experience can help to clarify. My patient presented to ER with gangrene of 2nd right toe and was admitted for surgical amputation of the toe. He also has cellulitis in his right lower extremity and the beginning of 2 more lesions on his left foot/toes. He is on 4 different IV Abx and is allergic to PCN. He does not have any lung/breathing problems; has Hx of htn and an MI but is on no cardiac meds or antihypertensives other than Lasix at home. He is a diabetic, obese, lives alone, is depressed, cannot ambulate with out assistance, and noncompliant with his diabetic regimen. Our instructor allows us to use Infection (not just risk for) as a diagnosis. I know my diagnoses can/will include the following: Perfusion, ineffective peripheral tissue; Infection; Impaired skin integrity; Ineffective Health Maintenance, Imbalanced Nutrition More than Body Requirements, Risk for Falls/Injury, Impaired Mobility and something to do with depression (am not sure where that goes). I am thinking that my Infection should be my first one....but am wondering if maybe the Ineffective Tissue Perfusion should be. Can anybody help me decide? Thanks in advance.

[Diver Dude]

I had a Pt. very similar to this. Very difficult but you're on the right track with tissue perfusion, fluid balance, relateld diagnoses. I don't have my care plan book handy but there are some good resources on the web that can "walk" you through some scenarios of a similar situation. A pt. like this will have lots of teaching around diet... and in the case of mine, the clinical outcome was a BKA after attempting to save his foot.

Keep at it and let us know what you find out. I'll check back later.

Steve

[ChristineWV]

Thanks for the reply. I am assigning the Ineffective Peripheral Tissue Perfusion, a Maslow 1, as my first priority, and then the Infection/Risk for Infection, a Maslow 2, as my second. If it were just a Risk for INfection and not an active infection, I wouldn't be having the problem because an actual diagnosis always "trumps" a Risk for...but our instructor uses Infection as a NANDA diagnosis...so in my mind, I'm asking "Which will kill him first"...and keep coming up with "Infection"...but am afraid to put it first since it's a Maslow 2 and not a 1! Argh!!!

[nursevandy]

2 things to ALWAYS REMEMBER...ABC's and SAFETY. Circulation should definitely be your first ND. Then, ANYTHING that can compromise his ABC's and/ or safety (if not already present). Hope that helps...by the way, remember those 2 tips...ABC's and SAFETY...VERY important with state boards.

[ChristineWV]

NurseVandy thanks for the reply. I definately left it at #1 spot with Infection as my #2; but still had a tinge of doubt - I think it's from only having one more week left in this semester and being a bit brain-dead. I still get confused with the infection diagnosis...it seems to me that gangrene would definately kill the patient before Ineffective peripheral perfusion (cardiac or cerebral I can definately see as killing them first)...but I went with the perfusion since that is what we are taught. What is your opinion? It's kind of a "chicken or the egg" thing as well...the ineffective perfusion definately caused the gangrene, but the infection could lead to septicemia and organ failure....it's all so confusing! I can't wait to be done with all of this.

[MunoRN, RN]

In terms of "real" diagnoses, the patient does have an active infection not just a "risk for", which has the potential to become sepsis which is more of an ABC threat than distal extremity tissue perfusion.

[ChristineWV]

Thank you...why doesn't NANDA list Infection as a diagnosis?

[nursevandy]

Be it, your client is on IV Abx, 4 at that, I would evaluate the labwork prior to making infection a priority ND. It could be 1, but not a priority...of course, if his labwork indicates compromise in the immune system, then most definitely it should receive higher priority. So check your labs...keep in mind, an abundance of abx can also cause a superinfection which can be masked...THE MYSTERY OF SCIENCE...LOL...Good luck...

[Esme12, ASN, BSN, RN]

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/Constructor.cfm

great link!

[fromtheseaRN, BSN, RN]

Thanks for the reply. I am assigning the Ineffective Peripheral Tissue Perfusion, a Maslow 1, as my first priority, and then the Infection/Risk for Infection, a Maslow 2, as my second. If it were just a Risk for INfection and not an active infection, I wouldn't be having the problem because an actual diagnosis always "trumps" a Risk for...but our instructor uses Infection as a NANDA diagnosis...so in my mind, I'm asking "Which will kill him first"...and keep coming up with "Infection"...but am afraid to put it first since it's a Maslow 2 and not a 1! Argh!!!

you're right on. i do it by "ABC, kill, maim, pain".

tissue perfusion will fall under your abc's, infection next under kill (risk for sepsis).