Help with my actual nursing dx!

[guerrerop22]

Hello all,

I am looking for some feedback from you on my actual dx for my patient. Here's the info:

67 year old male presents to hospital after a non healing blister that appeared spontaneously two week ago burst and became infected. The blister/wound is now covered with eschar and mild erythema is seen surrounding the wound. No presence of exudate. Left leg is edematous and is being measured q8hrs. Pt. has a hx of DVT in his entire left leg, hx of diabetes, hx of HTN. Pt. is on warfarin, various antibiotics via IV (is in process of getting a PICC line), oral antidiabetic agents, and HTN meds. VS are T 97.5 P 50 R 16 BP 134/70 Blood glucose 115. Pt. is not complaining of any pain at the current time. Doctors were debating whether to debride or do surgery and finally settled on just leaving it to heal on its own b/c of his risk for bleeding.

Okay, so I know that since my patient has diabetes it is going to take a long time for that wound to heal and even more so because of his DVT. I'm stuck between impaired tissue integrity and ineffective peripheral tissue perfusion.

My dx would look like this:

1. Impaired tissue integrity r/t altered circulation secondary to T2DM, DVT, and edema AEB purplish/blue discoloration of left foot, swelling in left leg, redness and tenderness around site of injury

or

2. Ineffective peripheral tissue perfusion r/t hx of DVT AEB purplish/blue discoloration of left foot, swelling in left leg, nonhealing skin blister

Also, an at risk dx (which I also need to do) could be at risk for bleeding r/t to currently on warfarin

Are my dx good? I appreciate any input!!

[edmia, BSN, RN]

My first instinct is #2. But I have not looked at a nanda book since I graduated, so don't quote me ;-)

I think the peripheral perfusion problem is really the root issue and so the better diagnosis.

Sent from my iPhone using allnurses.com

[Esme12, ASN, BSN, RN]

What semester are you? They are both essentially correct......you can only choose one? Has a diagnosis of DVT been made as being current? Or that the patient has had one in the past......hence the Warfarin

Your second diagnosis needs some rewording.....According to NANDA I, Ineffective peripheral Tissue Perfusion is defined as....a Decrease in blood circulation to the periphery that may compromise health.

That has the Defining Characteristics of:

Absent pulses; altered motor function; altered skin characteristics (color, elasticity, hair, moisture, nails, sensation, temperature); blood pressure changes in extremities; claudication; color does not return to leg on lowering it; delayed peripheral wound healing; diminished pulses; edema; extremity pain; paresthesia; skin color pale on elevation.

That has these Related Factors (r/t):

Deficient knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility); deficient knowledge of disease process (e.g., diabetes, hyperlipidemia); diabetes mellitus; hypertension; sedentary lifestyle; smoking

So...... your patient has Ineffective peripheral tissue perfusion r/t diabetes, HTN AEB purplish/blue discoloration of left foot, swelling in left leg, non-healing skin blister....that they have had a DVT in the past is relevant to this patient right now.

Your first diagnosis also needs tweaking......

Impaired tissue integrity r/t altered circulation secondary to T2DM, DVT, and edema AEB purplish/blue discoloration of left foot, swelling in left leg, redness and tenderness around site of injury

According to NANDA I Impaired Tissue Integrity is defined as: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.

With the Defining Characteristics of:

Damaged tissue (e.g., cornea, mucous membrane, integumentary or subcutaneous tissue); destroyed tissue

That has these 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

Or would this be more appropriate as there is more involved than subq tissue?

Impaired Skin Integrity

NANDA-I Definition

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

[h=5]Internal[/h]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

[guerrerop22]

Thank you! This all really helps! He currently has "nonocclusive DVT of left common femoral, superficial femoral, and popliteal veins". I'm a second semester nursing student but this is our first semester of clinicals and care plans. I just have to choose one but I wanted it to be the one with the highest priority.

[nurseprnRN, BSN, RN]

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. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.)Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.