One Full nursing Diagnoses

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Hello, I am a first semester nursing student and need to come up with a care plan which includes:

1. One full diagnoses (Name of diagnoses, reason (related to), and defining characteristics.

2. Objectives/Goals- Long and Short Term

3. Interventions

4. Rationale

5. Evaluation

My patient is a morbidly obese male in the orthopedic unit recovering from resection of a benign thigh tumor (desmoid fibromatosis) (50-60 cm). I looked at his chart and lab values and they are all within normal limits. I drained his JP drain and it looked red/pink, which looks like it was on track to healing. I assessed for pain and it was 9/10 and decreased to 5/10 after the morphine injection. When I came back from lunch he was again in pain and scaled it 8/10. I told the nurse and she again gave him morphine. By the time I left, it was 3:30 PM and he was again feeling better and rated his pain at 5/10. He told me that he was on bedrest for that day and will start physical therapy the next day. The three Diagnoses I can come up with are:

1. Acute pain rt surgical wound secondary to resection of thigh mass aeb wincing and rating pain scale 9/10.

2. Risk for delayed surgical recovery r/t morbid obesity, aeb difficulty in moving about ? ? (I wanted to use this one but having trouble)

- In my Mosby's guide it says that obesity is a related to factor in delayed surgical recovery... but my patient did not seem to have any other signs of illness or disease. I do know that he can only walk about 1 block with a cane.

3. Imbalanced Nutrition r/t intake more than the body needs aeb tricep skin fold >15 mm in men and bmi of 70.

Any suggestions would be greatly appreciated.

Thank you in advance!

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Specializes in Legal, Ortho, Rehab.

http://nursing-concept.blogspot.com/2009/02/free-nursing-care-plans-based-on.html

Try that. Is the delayed surgical recovery a new diagnosis? Think about impaired mobility as well. I don't know if it's ok to use "morbid obesity" in your nsg dx. It may be considered medical...but I'm not sure myself on that one, if it's in the book maybe it's ok to use?

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Thanks so much for your response and the link!

Not sure if it is a new diagnosis but it is in the 2nd Edition Mosby's Guide to Nursing diagnosis. Delayed Surgical Recovery's defining characteristics include : difficulty moving about, evidence of interrupted healing of surgical site (eg. indurated healing), perception that more time is needed to recover, loss of appetite, etc.

Related factors are: extensive surgical procedure, obesity, pain, post op surgical area infection, etc.

I will start looking into impaired mobility as well!

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Always Always main your 1st diagnosis the priority. So if there are no issues regarding the ABC's and no abnormal bleeding then always make your next priority PAIN - especially with this pt being post-op and still in pain enough to receive morphine. So: Acute Pain r/t (what he had done) aeb pain scale rating of ...... That is all you need. Keep it simple :) Shelly

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That makes a lot of sense. Thank you for the reminder that prioritizing on the ABC's physiological needs and keeping it simple is always good.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

a care plan in a list of the patient's nursing problems (those are the things you will give a nursing diagnosis to) and strategies to do something about them (nursing interventions). in order to determine what nursing problems are present we first assess for what is abnormal about the patient. from the information you posted i come up with this list of abnormal data:

  • morbidly obese and had a resection of a benign thigh tumor (desmoid fibromatosis)
  • jp drain and it looked red/pink
  • pain was 9/10 and pain of 8/10
  • on bedrest for that day

these are all evidence that we translate into nursing problems and place a name (nursing diagnosis) onto:

  • impaired physical mobility
  • impaired tissue integrity
  • acute pain

your goals and interventions are aimed at the evidence that supports each of the diagnoses. this is why assessment is so important and is crucial to the foundation of care planning. rationales are merely explanations of why you are performing a nursing intervention. evaluation is determining if your interventions met the goals you set for each particular nursing diagnosis. it is all related to that abnormal data and how it changed as a result of your interventions.

you should always read the definitions of any nursing diagnosis before applying it to someone. the definition of the nursing diagnosis of delayed surgical recovery is extension of the number of postoperative days required to initiate and perform activities that maintain life, health and well-being (page 127, nanda international nursing diagnoses: definitions and classifications 2009-2011). while obesity is one of the related factors for this diagnosis, post-op infection is often why it is used because it delays healing. if the patient's obesity was causing him to stay in bed and refuse to participate in physical therapy then using this diagnosis would be appropriate. however, if being on bedrest and starting pt tomorrow is the normal course of recovery for this kind of surgery, then delayed surgical recovery is not what is going on here.

for examples on the construction of care plans, see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

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