Help! Trouble w/ Nursing Diagnosis

  1. I have this assignment to do a case study for a mock patient. I have to come up with 2 diagnoses, goals, outcomes, interventions, rationales. I'm not sure i'm really understanding this.....when we go over it in class it seems pretty straight forward but now i'm confused. Here goes.

    It's a 68yo patient w/ newly diagnosed diabetes mellitus. Several sores on feet. Gained 50lbs. in 1 yr. Doesn't excercise or follow a diet. Asks you "I don't need to follow a special diet do I? You can give me meds, right? I don't have time for this."

    So my inclination for the priority diagnosis to be impaired skin integrity r/t deficient knowledge of proper foot care secondary to diabetes mellitus aeb several sores on bottom of feet.

    So what do I base my goals on? The sores or the proper foot care????? I'm all turned around.
    •  
  2. 10 Comments

  3. by   michar
    Quote from dex77
    Doesn't excercise or follow a diet. Asks you "I don't need to follow a special diet do I? You can give me meds, right? I don't have time for this."
    I'd make sure this was addressed at some point.
  4. by   locolorenzo22
    Yep, I'd make double sure you offered patient teaching on proper diet and meds alone won't fix this health condition. I'd go with deficent knowledge r/t diet, exercise for dx of diabetes mellitis as a nursing dx and base goal off of that. Patient will describe one healthy food alternative to subsitute into diet. Also, patient will show ability to keep sores clean/dry and free of infection related to hygeine.....(just a thought)
  5. by   dex77
    Thanks, I like the clean, dry, free of infection thing. I am going to write about the deficient knowledge of diet and excercise related to diabetes diagnosis. I was having more trouble w/ the foot care thing. I wasn't sure what my goals should relate to....healing wounds or education of foot care.
  6. by   NurseyBaby'05
    Knowledge Defecit for sure. Also,

    Altered skin integrity
    Risk for Infection
    Ineffective Individual Coping
    Noncompliance
    Nutrition Alteration: More than Body Requirements
    Risk for Powerlessness
    Health Maintenance Alteration
    Risk for Injury
    Risk for Ineffective management of theraputic regimen

    Hope these help.
  7. by   dex77
    Thanks for your feedback. This is the first case study we've had to do so i'm a little lost. (This is only my 5th week of nursing school). I hope it gets better.
  8. by   Daytonite
    hi, dex77!

    first of all, you need some guidance in getting to your nursing diagnoses. the proper procedure is to list the patient's symptoms which you have done. so, have i.
    • sores on feet
    • 50 lb weight loss in one year
    • no exercise
    • no diet
    • "i don't have time for this"
    these symptoms, or defining characteristics, are then used to match up to nursing diagnoses. each nursing diagnosis has a definition, defining characteristics (symptoms) and related factors (causes). if you have a nursing care plan book or nursing diagnosis book to help you out here you will find an explanation of this in the very beginning of the book.

    impaired skin integrity is indeed one of the diagnoses to attach to this patient. however, you cannot use deficient knowledge of proper foot care secondary to diabetes mellitus as the causative factor, or "related to" item in your diagnostic statement. there are a couple of reasons for this. (1) you can't use a medical diagnosis in a nursing diagnostic statement. (2) not knowing how to take care of her feet is not the cause the sores on her feet. you need to do some reading on diabetes and it's side effects. that is part of the purpose of doing these case studies anyway. the sores on this patient's feet are primarily the result of some small trauma, but we'll never know exactly what it was since that information wasn't given. the diabetes did the rest of the damage due to poor circulation. so, since you don't have definitive proof that the patient stubbed her toe or stepped on a nail, you work with what you know about diabetes, which is that it causes problems with peripheral circulation. therefore, i would revise this nursing diagnosis to read as follows: impaired skin integrity r/t altered circulation aeb sores on feet. it's that simple, because that's all you have to work with. there should be other symptoms, but you weren't given them. outcomes for this diagnosis include healing of the skin surface and the patient describing what they are going to do to protect, care for, and promote healing of the sores on the foot. you always want to involve the patient in the final formulation of outcomes if you want to get any cooperation from them. a goal is going to be to get the patient to demonstrate to you how to perform wound care as ordered by the doctor. your nursing interventions will concern the care of these sores as well as teaching the patient how to care for them. the rationales are merely the reasoning behind choosing each intervention, or "why" that intervention is going to work.

    with any newly diagnosed medical condition, there is always need for teaching the signs, symptoms and treatment for the disease. so, deficient knowledge of disease process r/t lack of information aeb apathetic behavior toward condition [the statement "i don't have time for this" is apathy] should be your second nursing diagnosis for this patient. outcome will be for the patient to be able to explain what diabetes is, what medications he/she needs to take to keep in under control, and what treatments need to be done to heal up the sores on the feet. also, the patient needs to explain how he/she is going to work all this into their present lifestyle.

    now, i want to turn to the 50-lb weight loss. the 50-lb weight loss is a good symptom of undiagnosed diabetes. other symptoms are missing, but the weight loss sticks out like a sore thumb, especially since the patient has not been following any kind of a diet. why does a person with undiagnosed diabetes loose weight? you need to find the answer to that question. it has to do with the pathophysiology of diabetes and it is a very important point that you need to know the answer to. this patient should have had other symptoms of her diabetes such as thirst, hunger and excessive urination. this all goes along with the weight loss in a diabetic who is newly diagnosed. so, another potential nursing diagnosis here would be ineffective health maintenance. the definition of this diagnosis is: "inability to identify, manage, and/or seek out help to maintain health." (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 90) the nursing diagnostic statement would be: ineffective health maintenance r/t knowledge deficiency in caring for disease condition aeb inability (or refusal) to recognize symptoms of illness. your outcome with this kind of patient, hopefully would be for the patient to follow a mutually agreed upon plan for maintenance of his/her diabetes. one goal might be to have the patient discuss why they resist seeking medical help. this patient has an obvious attitude problem that needs exploring, and has to change (although you can't make them change it) if they want to survive and live a comfortable life. you can also put your patient teaching of diabetes under this diagnosis, but only if you don't use deficient knowledge of disease process as a nursing diagnoses.

    a fourth nursing diagnosis is risk for noncompliance. with statements like "i don't have time for this", it is likely that this patient is going to have a problem with controlling their disease, if they even bother to. i've seen this over the years as a practicing nurse. there are some very stubborn diabetics out there who just do not want to take any responsibility for managing their condition. consequently, they are frequent visitors to the emergency rooms and doctor's offices for all the problems that go along with diabetes. so, risk for noncompliance r/t patient's behavior is a diagnosis i might use. there are no aeb items attached to "risk for" diagnoses because they are problems that do not yet exist. however, with this patient, i think there is a good possibility that he/she is not going to follow medical advice. outcomes would be to have the patient verbalize understanding of his/her disease and treatment, to agree to follow through with treatment plans.

    there are 4 possible nursing diagnoses and outcomes to get you started. read up on diabetes! that's another reason why instructors give case studies--so you learn about the disease condition itself. diabetes is one of those medical conditions that has lots of problems connected with it. care plans for diabetics can become quite extensive and long. the four nursing diagnoses i've suggested are only the tip of the iceberg. good luck!
  9. by   MegNeoNurse
    I don't know if this is answering your question or not, but my school told us that we need to have 1 care plan per nursing diagnosis. Like, one diagnosis/etiology/symtomology, one goal and outcome criteria, 1 nursing responsibilities, supporting rationale, and eval mod per nursing diagnosis. Our school also told us that we should choose that most critical diagnosis to take care of first (this is while we're getting used to the concept.)

    If that makes sense to you?
  10. by   Daytonite
    Quote from CSM08MMS
    I don't know if this is answering your question or not, but my school told us that we need to have 1 care plan per nursing diagnosis. Like, one diagnosis/etiology/symtomology, one goal and outcome criteria, 1 nursing responsibilities, supporting rationale, and eval mod per nursing diagnosis. Our school also told us that we should choose that most critical diagnosis to take care of first (this is while we're getting used to the concept.)

    If that makes sense to you?
    Actually, no. You want to try explaining that again?
  11. by   dex77
    Wow! Thanks for the info! My case study was due this morning. We were supposed to do only 2 diagnosis. I guess my problem was both that I don't really know what they are expecting from us AND the care plans were explained in a very simplified way. That was pretty much what I gave back. I actually did do a report in A&P on diabetes and I am aware of all of the other issues. BUT-they didn't seem to be looking for a lot of detail. I was trying to stay true to the information that they did give as symptoms. One of the examples we went over in class was similar but they gave the impaired tissue perfusion (peripheral) based on other symptoms that were more obvious (like poor capillary refill). That was why I was moving in the direction of impaired skin integrity. Thanks for the detail though. I will refer back to it for my next case study assignment.

    This program seems to be full of surprises. Many of us do not feel well informed about what we are supposed to know....there seems to be a disconnect between the teaching staff and the students. The teachers don't want to answer questions and when they do they are very unclear. :uhoh21: I wonder if this is because it is an ADN program?????? Are BSN programs better about this stuff????? I'm beginning to feel like i'm in a bad program.
  12. by   Daytonite
    It's quite possible that your instructors are just trying to awaken your abilities to think critically. My instructors 30 years ago wouldn't answer our questions directly either. One of the things that you have to do throughout your study of nursing is to ask yourself "why". Why is this happening to the patient? Why is the doctor ordering this medication? Why does my nursing book say I should be doing this for the patient? Yes, you are right in going with what the case scenario is actually telling you. However, as time goes on you will be expected more and more to have an understanding of what and why things are going on with a patient. It helps in the planning of their care. In the particular case scenario you posted about, the connection between the diabetes and the sores on the feet was very clear to me. The poor circulation from the diabetes, some unknown injury (known or unknown by the patient) and, wham-o, you've got a diabetic with a open wound. The wound is subject to infection, non-healing and possible amputation without proper care. Now, none of that was part of the scenario that was presented, but nevertheless, it was in the back of my mind. So, if I were actually doing a care plan on this patient I would include other diagnoses such as Risk for Infection. Then, this guy says he doesn't have time for all this and the scenario alludes that he just wants some medication to take care of it and he's out of there. This is clearly an indication that he needs education about diabetes. He's definitely got a problem with not caring what his medical problem is as well. That may or may not clear up when he is educated about diabetes. A lot depends on how open and motivated he is going to be to learning. So, you see, this, then, is how you are going to take all that information you learned in all those pre-requisite classes you took, think on it and put it together with clinical information about the patient. Kind of exciting, isn't it? This is what separates the professional licensed nurse from those who just give the basic hands on nursing care.

close