Nursing Diagnosis

[KrCmommy522, BSN, RN]

Hello! I just got back from the hospital doing research the night before my clinicals. One of the pts I chose is a 50 y.o. woman with diabetes who has cellulitis on her left thigh and an abscess. Tomorrow she is going to have debridement/I&D for the cellulitis. I am suppose to do the first 2 pages of my care plan for my pt based on the research the night before and then we finish it after clinicals once we've been able to assess the pt and spend the day caring for the pt. So I am trying to come up with my primary nursing Dx based on what I know so far. I am thinking of Acute Pain r/t inflammatory changes in tissues from infection. My question is, should I leave it just like that or should it be Acute Pain r/t inflammatory changes in tissues from infection secondary to abscess?

Thanks!

[BeachsideRN, ASN]

Did you see the patient or just view the chart? Is s/he in significant pain? It's kinda hard to create a careplan/make a nursing diagnosis without assesment data. Though from what you've learned thus far, think about what else is going on with this patient physiologically.

[KrCmommy522, BSN, RN]

When I posted this I had just reviewed her chart, but now I have seen her. She is in significant pain. The abscess is really deep, and there was a lot of pus/drainage coming from it. It went all over the bed, floor, everywhere that we had to clean up and then repack the wound. She went in to surgery to have it debrided thursday evening. But other than the abscess, drainage, and her being in so much pain, she didn't have anything else symptom wise. She is overweight, has DM, and her BS levels were high even though she was NPO.