Care plan nursing dx help RT diabetic teaching

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    Hi, I'm trying to do two care plans on a pt who has unstable diabetes. He has been taught about a proper diet, but he has stated that even though he knows he should follow it, he does not because he doesn't enjoy the food. He also has neuropathy and cellulitis of the feet and was admitted because he had stepped on a rusty screw and failed to realize that it was in his foot for 3 days. So I would like to go over the importance of diabetic foot care with him. I'm just not sure how I should do my nursing diagnosis and RT part? This is my first year so I haven't quite gotten the hang of it yet. Any help would be really appreciated.
    Also, would a screw penetrating his foot be considered impaired skin or impaired tissue?
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  3. 3 Comments so far...

  4. 1
    Is this care plan specifically for teaching only? Or are you supposed to do a care plan in general. Teaching is a part of your care plan.

    Here is what I know.....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.

    What is your assessment? What are the vital signs? What is your assessment. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

    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. I use
    Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

    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

    1. 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)
    2. 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)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. 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.


    Now tell me bout your patient....What do they complain about? What are your vital signs? What is your assessment? What care plan book do you use?
    pmabraham likes this.
  5. 1
    Quote from Krisza
    Hi, I'm trying to do two care plans on a pt who has unstable diabetes. He has been taught about a proper diet, but he has stated that even though he knows he should follow it, he does not because he doesn't enjoy the food. He also has neuropathy and cellulitis of the feet and was admitted because he had stepped on a rusty screw and failed to realize that it was in his foot for 3 days. So I would like to go over the importance of diabetic foot care with him. I'm just not sure how I should do my nursing diagnosis and RT part? This is my first year so I haven't quite gotten the hang of it yet. Any help would be really appreciated.
    Also, would a screw penetrating his foot be considered impaired skin or impaired tissue?
    Your care plan is about the patient assessment....tell me about your patient. He apparently has knowledge deficit about his diet for diabetics eat regular foods...minus the sugar just in different amounts. Do you have a good care plan book? This is imperative to getting the "hang of" care plans. Several nursing diagnosis's come to mind as I look at the information you gave me....I see that the patient has
    1) Deficient Knowledge (specify) : diet, foot care
    2) Ineffective self Health management: not performing foot care and following diet
    3) Disturbed Sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory): neuropathy
    4) Readiness for enhanced Self Health management: following a medical regime
    5) Readiness for enhanced Self-Care: ready to improve their health and care

    As well as both of these....look at your NANDA I definitions.....

    NANDA I Definition

    Impaired tissue
    : Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues
    Defining Characteristics: Damaged tissue (e.g., cornea, mucous membrane, integumentary or subcutaneous tissue); destroyed tissue
    Related Factors (r/t): Altered circulation; chemical irritants; fluid deficit; fluid excess; impaired physical mobility; knowledge deficit; mechanical factors (e.g., pressure, shear, friction); nutritional factors (e.g., deficit or excess); radiation; temperature extremes
    NANDA-I Definition

    impaired skin
    : Altered epidermis and/or dermis
    Defining Characteristics: Destruction of skin layers; disruption of skin surface; invasion of body structures
    Related Factors (r/t):
    External:
    Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation

    Internal: Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence
    Jill2Shay likes this.
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    You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.


    There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it.


    Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.


    For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each. Note that these may not apply to YOUR patient, so no fair (and not smart) to lift them entire for your homework.


    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)




    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.


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


    "Related to" means "caused by," not something else. In your original diagnosis (which isn't a nursing diagnosis, by the way) you said that altered hepatic function was caused by jaundice, which is, of course, exactly backwards. But since you can't use "altered hepatic function" because it isn't a nursing diagnosis, we'll skip that.


    To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition).


    So, for example, if you use "neonatal jaundice" as your nursing diagnosis, you discover that the support you need for that includes the following in the NANDA-I 2012-2014:


    Defining characteristics (must have at least one): abnormal blood profile (a number of lab results given...look in the NANDA-I to see what they are); abnormal skin bruising; yellow mucous membranes; yellow-orange skin; yellow sclera


    "As evidenced by" means "these are the defining characteristics I observed/learned about in the chart." The related factors are in the NANDA-I too.


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