A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize?
A) Disturbed Body Image
B) Impaired Skin Integrity
C) Nausea
D) Risk for Deficient Fluid Volume
Ans: B
Feedback:
While each of the diagnoses may be applicable to a patient with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation.
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Fill in the blank(s) with the appropriate word(s).