Stumped on Nursing Diagnosis for Episiotomy

Marie_LPN, RN, LPN, RN · Nov 24, 2004

What would you consider the classification of the wound?

That might help you with an answer.

lil' girl, LPN · Nov 24, 2004

Look at the question again, impaired skin integrity, what would you see IF the skin was impaired after surgical incision?

shel_wny · Nov 24, 2004

Edema and bruising. Thanks! You guys gave me just the push I needed. :)

I really have no idea about how to classify a wound...we haven't done anything like that. :imbar

Shel

Nurse Ratched, RN · Nov 24, 2004

(alteration in comfort) :)

Edited to add: pain is always a hit with the nursing instructors.

Lasoniamacaroni · Nov 24, 2004

How about...

Risk for infection r/t a site for organism invastion secondary to episiotomy.

shel_wny · Nov 24, 2004

(alteration in comfort) :)
Edited to add: pain is always a hit with the nursing instructors.

Ohhhh acute pain. That's a good one!

Yeah, our instructors are on the "pain is the fifth vital sign" trip too which is pretty cool, actually. Lots of older, experienced nurses that I work with don't really care too much about pain and it bothers me.

Shel

Marie_LPN, RN, LPN, RN · Nov 24, 2004

The only thing about pain (because i used that as an answer once and got it wrong) is that our instructors wanted "evidence" that you could see. Pain is what the pt. tells you it is, the edema and bruising the nurse can see for themselves.

shel_wny · Nov 24, 2004

The only thing about pain (because i used that as an answer once and got it wrong) is that our instructors wanted "evidence" that you could see. Pain is what the pt. tells you it is, the edema and bruising the nurse can see for themselves.

I always got away with "Pain related to blah blah as evidenced by verbalization of pain at 5 on the pain scale."

My instructor is a stickler too! Does this seem right?

Nikki730 · Nov 25, 2004

pain can be evidenced by grimacing, whincing, or guarding too

kahumai, RN · Nov 25, 2004

"Knowledge Deficit r/t care of episiotomy AEB this being pt's first experience with one, pt asking questions about special care instructions, etc."

Tony35NYC · Nov 25, 2004

I agree with Marie. I always got big red Xs on my concept maps whenever I tried to use pain because the instructors say its redundant and that I'm being lazy. Risk for Infection of a perineal incision could be r/t poor wound appromixation, or contamination of the site with fecal matter. Anything that affects metabolic and cardiopulmonary processes also increases risk for infection so if she's got altered circulation, altered respirations, altered nutrition status, immunocompromised, etc you could relate these to the risk for infection as well