Question

A client has an eviscerated surgical wound with moderate exudate. The vital signs are: Temperature 100.1, pulse 108, BP 108/58, respirations 26, and a white blood count of 13,200/mm3. Which nursing diagnosis is a priority for this client?

a. Decreased cardiac output R/T surgical procedure AEB: Pulse 108 and BP 108/58
b. Infection R/T open wound AEB: Temperature 100.1, WBC count of 13,200/mm3
c. Skin Integrity, Impaired R/T disruption of dermal tissue AEB: open wound and exudate
d. Thermoregulation Ineffective R/T bacterial invasion AEB: Temperature of 100.1

Answer 1

The priority nursing diagnosis for the client is 'Infection related to open wound' indicated by an elevated temperature and white blood cell count, aligning with the body's physiological response to infection, which takes precedence over other potential diagnoses.

Step-by-step explanation:

Prioritizing Nursing Diagnosis

The priority nursing diagnosis for a client with an eviscerated surgical wound and moderate exudate, exhibiting vital signs of a temperature of 100.1, pulse 108, BP 108/58, respirations 26, and a white blood cell count of 13,200/mm3, would most likely be Infection related to open wound as evidenced by the elevated temperature and white blood cell count. This diagnosis is supported by the physiological response of the body to likely infection, which can be acute or chronic and can develop rapidly in a surgical wound, potentially leading to sepsis if not properly managed.

An increased pulse and lower-end normal blood pressure may reflect the body's response to an infection, although it could also be related to decreased cardiac output.

Impaired skin integrity is also present, as indicated by the open and draining wound, but the presence of systemic signs such as fever and leukocytosis gives precedence to the diagnosis of infection. Ineffective thermoregulation is less of a priority compared to the direct threat posed by a possible infection.