NCP, Laboratory test implications,, - page 2

i have a patient who is male,35 years old... slightly obese, has diabetes mellitus... his CC is intolerable pain.. its due to a 2inches long and half inch deep wound... upon observation pus... Read More

  1. by   Virgo_RN
    I disagree. I don't think asking for answers on an internet bulletin board is very resourceful, and I feel no obligation to just hand someone the answer.
  2. by   drew9319
    you can disagree if you want. thats your right. never said you had to hand him the answer either
  3. by   Virgo_RN
    Quote from drew9319
    you can disagree if you want. thats your right.
    Gee, thanks. I didn't know that.

    You can help him your way if you want.
    Last edit by Virgo_RN on May 10, '09
  4. by   Jjearkwein
    well im just a nube at the nursing world(1st year)...we were sort of advance class due to a special(testing) curriculum(four year course and preclinical late 1st year), this constitutes 30% of my grades... so if i dont want to stop taking nursing for 1 year and take the 5 year course i need to give my best shot... maybe you guys noticed but i was working w/ this case for soon to be 24 hours(i have recent posts)..


    im not asking for direct answers... i want to understand whats happening...
    i know that having infection is a greater threat to the patients life.. but since i cant find the right diagnosis i settled for pain...(since i dont know any, and saying"risk for infection" is not applicable{i think} since he already has infection)...

    "Infection,????" then what... i really cant find anything on the net... thus when i saw this site i was eager to ask questions..

    just tell me what to do, links or so....
    any help is much appreciated..
    sorry for the troubles..
  5. by   drew9319
    no trouble. if you read the posts here this happens. alot. nurses disagree on how to do things all the time. its just the way we are. everyone brings their own flare and methods to the game. if you make it through you will too.
  6. by   morte
    not to be a nit picker, but the patient really isnt febrile, that was a PR temp......
  7. by   drew9319
    the temp i saw was 37.8 C. the PR of 102 i though was the pulse. that was my take anyway.
  8. by   UM Review RN
    Moving to Nursing Student Assistance forum. If you look on the upper right, you'll see a tab for Students. Lots of help there.
  9. by   morte
    Quote from drew9319
    the temp i saw was 37.8 C. the PR of 102 i though was the pulse. that was my take anyway.
    ah, maybe indeed....an opening for "dont use unapproved abbr." have never seen or used PR for pulse rate...HR for heart rate, but pulse has always been just "P".....
  10. by   drew9319
    use very much so. we usually use hr for the pulse or just P. the unapproved abbreviations is a whole other coversation :smilecoffeecup:
  11. by   Jjearkwein
    since i cant Choose which Dx are to be used.. i figured out ill just do them all..

    1)"Pain related to infection of wound on the right foot"
    2)"Infection related to impaired skin integrity as evidenced by pus:"
    3)knowledge in woundcare. "Deficit Knowledge"
    4)Knowledge in illness. "deficit knowledge"

    are this right?

    i dont have any nanda book yet..
    please help me... i have until tonight to finish my work...
    Last edit by Jjearkwein on May 10, '09 : Reason: got something..
  12. by   drew9319
    try nursingcrib.com they have searchabel careplan samples. for nada, nic and noc..you'll have to buy the books
  13. by   SolaireSolstice
    1)"Pain related to infection of wound on the right foot"
    2)"Infection related to impaired skin integrity as evidenced by pus:"
    3)knowledge in woundcare. "Deficit Knowledge"
    4)Knowledge in illness. "deficit knowledge"

    are this right?

    i dont have any nanda book yet..
    please help me... i have until tonight to finish my work...
    You need to get a Nanda book. They are your bible for this sort of work. Lots of people also recommend care plan books, but after your 3rd or 4th clinical you may not need it (the care plan book) anymore, so try to find one used. Go get your Nanda book TODAY. Whichever one your school recommends.

    1) Pain is classified as aute or chronic, acute being <6 mnths in duration, chronic > 6 mnths. Pain is measured through a pain scale (1-10) or with a non-verbal patient, through behaviors (grimacing, guarding, crying out). That would be your manifested by (the scale or behaviors).
    2) You never use a nursing diagnosis as your "related to". Your "related to" is your factors that contributed to causing the diagnosis. The correct terminology wound be :
    "Impaired skin integrity related to (what caused the wound?) as manifested by ..."
    3) See 4
    4) Should be Deficient knowledge, but what is your assessment findings that support this diagnosis?

    Other things, I've never seen a laboratory value for glucose as +++. We all have glucose in our system. Values of between 70-110 are normal. I wouldn't even know how many + you need before it became abnormal and if there weren't any +s, can we assume hypoglycemia? This is incredibly nit-picky, but usually wounds, even here in the states, are measured in centimeters.

    Daytonite will be along shortly I'm sure, but in the meantime you should look up her posts and see her breakdown on how to turn an assessment into a careplan.

    Your nursing diagnosis will consist of the Nanda diagnosis (the problem you have identified through your assessment), the related to (the contributing factors that caused the problem, you aren't suposed to use a medical diagnosis here, you can use a medical diagnosis for secondary to, also shouldn't use another nusing diagnosis as the related to), secondary to (usually a medical diagnosis), as evidenced by (your assessment findings that support the diagnosis).
    IE: Impaired tissue integrity related to (what caused the wound?) secondary to infection as evidenced by wound of (size) with pus on the (where is the wound?).
    You prioritize your diagnosis based on the ABCs (airway, breathing, circulation) then Mazlows hierarchy of needs (look it up). I was taught to prioritize "Risk for" below actuals, and honestly, your patient has enough actuals to not even need risk fors.

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