Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to

(R/T), as evidenced by (AEB).

Problem #1 Pain r/t tissue injury secondary to necrotizing soft tissue

infection AEB pt. report of severe pain and grimacing
Desired Outcome: Pt. will remain at or below tolerated level of pain (as
expressed by patient on scale of 0-10) for duration of shift
Nursing Interventions
Client Response to Intervention
1. Assess pt.s tolerable pain level of
1. Pt.s tolerable level of pain Is
pain
a 2/10.
2. Administer prescribed pain
medication on time to be sure to stay
on top of pain management
3. Encourage additional nonpharmacologic pain management
techniques such as deep breathing
and/or minimizing excessive external
stimuli

2. This patient was getting

Dilaudid q3h. She was very
uncomfortable throughout the
day, so we made sure to get
this to her on time.
3. She liked having the lights
dimmed when we were not
doing any procedures or
assessments. She implemented
deep breathing for me a few
times, but she did not express
much interest in it.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would
you adapt if needed):

This was the primary problem for this patient today. She was
experiencing severe pain throughout the day. Unfortunately we
couldnt ever seem to get her pain lower than a 7/10. I discussed with
her assigned RN about possibly talking to the MD to get more pain
medication available and she did not think it was adequate. She
seemed to think that the patient had a history of drug use and that she
was milking the situation. I did not agree with this, but I kept my
opinion to myself. The patient had several very severe wounds so I
could completely understand that there would be associated
excruciating pain. The RN I was working with may possibly be correct,
but I just didnt want to make any assumptions or judgments about the
patient. I just wanted her to be comfortable.
Problem #2 Skin integrity impairment r/t infectious process AEB
redness and tenderness at areas of surgical incision for debridement
Desired Outcome: Pt. will not show any signs of worsening skin
integrity during shift AEB absence of: greater areas of redness,
induration around wounds, and foul smelling odor
Nursing Interventions
Client Response to Intervention
1. Assess wounds and measure area
1. I measured the area of

of redness.

2. Administer prescribed antibiotic

therapies.

3. Keep pt. skin clean and dry.

redness around the abdominal

wound dressing. It was pretty
consistently red for about 1-1
inch form the edges.
2. Administered prescribed
antibiotics on time and
stressed the importance to the
patient of taking them at the
scheduled time for every dose
to keep therapeutic levels
constant.
3. Effectively kept the skin
clean and dry.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would
you adapt if needed):
I think that was also a very appropriate nursing diagnosis for this
patient due to the severity of the wounds this patient had. The area of
redness surrounding the abdominal wound did increase to about 2
inches after the dressing change by the wound care nurses due to the
manipulation and irritation to the tissue, but resolved back to about 1
inches after a few hours had passed. We applied a hot blanket to the
area after the dressing change to help ease some of the pain. While I
do think this was a pertinent diagnosis, I would have liked to adjust the
outcome/goal for a longer period of time if I were able to make goals
that were for more than one shift because many different
complications can happen during wound healing so it is an ongoing
goal. I should have also included sterility of dressing changes in the
interventions because this is of utmost importance.
Problem #3 Deficient knowledge r/ new diagnosis of DM AEB tearing up
at times, and showing signs of depression such as tearing up at times
Desired Outcome: Pt. will verbalize 3 facts about managing diabetes
after education session by end of shift
Nursing Interventions
Client Response to Intervention
1. Assess pt.s current knowledge of
1. Pt. expressed that she didnt
DM mgmt
know very much at all about
the disease.
2. Teach pt. about blood sugar
2. We discussed food labels
monitoring, diet restrictions/carb
and the importance of
counting, and the purpose/action of
counting carbohydrate grams
insulin.
and that one carb choice =
15g of carbs. We spoke about
complex vs. simple carbs and
how the effect on blood sugar.

3. Teach about peripheral neuropathy

and importance of checking feet daily.

We talked about the role of

insulin in relation to blood
sugar and the importance to
blood sugar monitoring.
3. Pt. understood the risks and
understands why daily feet
checks are important.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would
you adapt if needed):
I went to the education room to find information to give, but
surprisingly there were not a lot of materials about diabetes in there
(at least not that I could find). I did find a pamphlet about the diabetes
classes offered at the hospital and I went over that with her. She was
on her computer throughout the day so I directed her to the American
Diabetes Association website, and I talked with her a bit while she was
navigating the page. I told her that there was a lot of great information
on the website and to ask any questions if they arise. She seemed a
little less anxious after discussing it with me.