60 yo female, acute osteomyelitis in R great toe

Esme12, ASN, BSN, RN · Apr 4, 2014

Care plans are all about the assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

Assessment
(collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis
(make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning
(write measurable goals/outcomes and nursing interventions)
Implementation
(initiate the care plan)
Evaluation
(determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Esme12, ASN, BSN, RN · Apr 4, 2014

elevant Health History:
History of morbid obesity (63", 347.8lb)
diabetes mellitus type2
Asthma
History of GAVE Syndrome (gastric antral vascular ectasia, aka watermelon stomach; acute or chronic gastrointestinal blood loss).
Hypertension
Chronic LBP
Irritable Bowel Syndrome
previous history of depression
LABS/TESTS:
WBC- 6 k/u
RBC 2.95 ml/ul
hemoglobin- 8.7 g/dl
hematocrit- 26.3%
Segmented neutrophils 68%
Lymphocytes- 14%
Eosinophils 7%
Sodium 135 mmol/l
Chloride 99mmol/l
Glucose 157 mg/dL
BUN- 24 mg/dl
Albumin- 3.2 g/dl
Uric Acid- 10.2
Magnesium - 1.6mg/dl
ASSESSMENTS:
c/o SOB with exertion
Stated "Pain 8/10" after peak time for pain medication administered.
Consumed outside food that family brought for her.
Requested more food from Nutrition dept. after breakfast was served and consumed.
T- 97.9
Bp 120/64
RR -14 regular
P-74, 2+, regular
Capillary refill

Just from the highlighted items....what ND applies? Did you do an assessment of her pulses? Is her glucose controlled? Could her need to keep her stomach full be from depression of is a a way to feel relief from the GAVE?

lwandel · Apr 4, 2014

Please let me know how I can improve this dx and the related goals, interventions and rationales.

I'm thinking I could go with either:

Fatigue r/t inadequate tissue oxygenation secondary to anemia

or

Activity Intolerance r/t compromised oxygen transport secondary to anemia and asthma

or

Activity Intolerance r/t inactivity secondary to secondary to sedentary lifestyle and discomfort with ambulation

I know that goals for fatigue focus on helping the pt adapt to the fatigue, and that activity intolerance goals focus on increasing tolerance to activity. I feel that, for this pt., I would like to focus the goals toward increasing activity.

So, here's what I'm thinking of going with:

Nsg Dx: Activity Intolerance r/t inactivity secondary to pain, dyspnea and sedentary lifestyle.

Goals:

By discharge, patient will not experience fatigue

AEB

1. Patient will be able to perform ADL's without c/o dyspnea.

2. Patient will be able to ambulate length of hall without complaint of fatigue.

3. Patient will maintain normal blood pressure 3 minutes after activity.

4. Patient will rate pain less than or equal to 5 out of 10 on a scale of 1-10 during ambulation.

Interventions / Rationales

1. Intervention: "Monitor and record the client's ability to tolerate activity: note pulse rate, blood pressure, O2 saturation, dyspnea, use of accessory muscles, and skin color before, during and after the activity" (Ackley & Ladwig, 2011, p. 120).

Rationale:"Response to activity can be evaluated by comparing pre-activity BP, Pulse, Respiration and O2 saturation with post-activity results. These are compared with recovery time" (Carpenito, 2008, p. 63).

2. Intervention: "Treat pain before activity and ensure that the client is not heavily sedated" (Ackley & Ladwig, 2011, p. 121). Rationale: "Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement" (Ackley & Ladwig, 2011, p. 121).

3.Intervention: Have patient perform active ROM at least twice a day.

Rationale: "Minimize the deconditioning effects of prolonged bed rest and imposed immobility".

4. Intervention: "Plan a purpose for each activity, such as walking to the window to see the view, or walking to the kitchen to get some ice water".

Rationale: Strategies that are individualized can increase motivation.

Please let me know how i can improve on this one. I'm going to work on the other 2 nsg dxs I need for this care plan.

Thanks,

lwandel

Esme12, ASN, BSN, RN · Apr 4, 2014

I like the last one you did.

Don't forget you as evidenced by.... Activity Intolerance r/t inactivity secondary to pain, dyspnea and sedentary lifestyle s evidenced by.....patient symptoms and statements.

lwandel · Apr 4, 2014

I am working on a second dx. I'm having trouble with this one. Here are my assessments so far related to this direction:

Data:

Obese- Ht. 63", Wt. 347.8 lb.,

60 years of age

sedentary activity patterns,

patient stated "I know I need to lose weight",

stated "I don't over eat. I control my diet well and I drink a lot of water",

observed pt. requesting family to bring outside food

observed pt. consuming outside food brought by family,

patient requested additional food from Nutrition dept. directly after consuming breakfast.

I don't know if this should go in the direction of Imbalanced Nutrition: More than body requirements, or Ineffective Health Maintenance...or is there a more psychosocial diagnosis that would help with this one?

This is what I've come up with so far for this pt.

Nsg Dx: Imbalanced Nutrition: More than body requirements r/t excessive caloric intake in relation to metabolic need.

Goals:

By discharge, patient will commit to a weight-loss program AEB

1. Client will state "I have committed to a weight loss program".

2. Client will demonstrate weight loss of 1-2 lbs per week.

Interventions/Rationales

1. Intervention: Advise client to complete 1 week food intake and exercise journal that records: food intake, type of exercise, amount of exercise, location of meals, time of meals, and emotions around meal time, snacks, people with whom patient eats.

Rationale: Overweight individual often report that their intake is less than it actually is.

2. Intervention: "Multiply female weight by 11 to determine caloric intake/day needed to maintain current weight. Teach patient that to lose 2 lbs./week, she must cut 7000 calories from weekly intake or increase exercise caloric expenditure".

Rationale: "Intake must be reduced by 500 calories/day less than requirement to obtain 1 lb/week weight loss".

3. Intervention: "Collaborate with Physical Therapy department to assist client with identifying a realistic exercise program" (Cupernito, 2008, p. 318).

Rationale: "Simplifying exercise regimens and tailoring them to individual lifestyles encourages adherence to exercise plan" (Ackley & Ladwig, 2011, p. 427).

Critiques requested and welcome :) Thank you!

lwandel

lwandel · Apr 4, 2014

Thank you Esme! I'm glad you liked it. My instructor has us list our Cues/Assessments on a different form, and cluster the cues/assessments in a group with each dx. It's strange, but that's how she likes it. Which is why I don't list the AEB's with the nsg dx...they're on a different form.

lwandel · Apr 4, 2014

I'm stuck on my 3rd diagnosis. I want to focus on her pain, because she consistently rated her pain as 8-9 out of 10 throughout my shift. Even after meds were given. It would drop down briefly to 7 at peak time, but would jump right back up to 9 out of 10. She was receiving pain medication every 1.5 hours to keep peak times in place. She was receiving morphine, hydrocodone, dilauded and tramadol. My pt. complained of both chronic back pain and acute pain in her foot r/t osteomyelitis. Since I'm dealing with both Chronic and Acute pain, should I go with a dx like Impaired Comfort? Impaired Comfort r/t Osteomyelitis?

lwandel · Apr 5, 2014

Or, instead of focusing on pain, since my instructor wanted us to use an "at risk for..." r/t medication given, I guess I could use

Risk For Electrolyte Imbalance r/t diuretic therapy, or would I need to get more specific with Risk For Hypokalemia r/t loop-diuretic therapy?

Ugh. Stuck on this one.

May 2014 · Apr 5, 2014

You're missing the big picture with your patient. That is chest pain, and SOB with exertion. That should be your priority if your careplan is to be individualized. After that, focus on nutrition, third, go to to education as your pt seems to have issues with risk factors for heart disease.

Esme12, ASN, BSN, RN · Apr 5, 2014

I think the pain is the osteo....I might be missing the mention of chest pain. But I saw it as the pain from the osteo.

OP the focus would be on pain as that is an important priority. Why is she SOB? Remember to prioritize you need to think about what can kill them first. ABC....Are her O2 sats low?

Risk for diuretic therapy is OK I don't think you have to mention loop diuretic but you would not be wrong to say so.

To address the exertional dyspnea would it be impaired gas exchange? What evidence do you have to support this diagnosis. Is she hypoxic? Does her sat drop? Is this fluid/failure based? or Asthma chronic lung based.

lwandel · Apr 5, 2014

Hi May, there was no complaint of chest pain, only dyspnea with exertion. Her pain stems from her low back and osteomyelitis. She does have risk factors for heart disease, but my instructor seem to want us to focus on psychosocial and "at risk for _____ r/t medication" at this point in our clinicals. But, since i also have an exam on tuesday, this care plan may not meet all of her standards. I think the pain issue is more relevant than the risk for electrolyte imbalance. so I will probably go with that one.

I do appreciate your comments :)

Thanks,

Leslie