identify cause

[Medsport, LPN]

I just completed my first "good" care plan last week. now we have to do 2 on 1 patient. It took my all day to do 1 last week. Anyway my client had a colonostomy and catheter and I'm trying to figure out what to put down for the cause of the in-dwelling catheter insertion. Would it be incontinence, urine retension or UTI? I don't remember reading it in his chart. He has necrotizing fasciitis (under control I think), DM, hypertension, PVD, depression, MRSA, decubitus ulcer, COPD, osteomyelitis and wound infection. He has atrophy and contractures of his legs and had colon cancer and hip surgery, had a g-tube, now removed. I'm also not sure what to put for the causes of limited movement, flexion contracture or legs and weakness or paralysis of legs with poor posture, body alignment. He does not walk, but can be transferred from bed to wheelchair with 1 assist and can move around in bed fairly easily. He does have a pressure ulcer on his coccyx and left heel that looks pretty bad. Also, I'm thinking that impaired tissue (or skin integrity) would be 1 Dx and impaired physical mobility another one for the care plan. Or would intermittant ab/hip pain or something about altered means of elimination be higher?

[Daytonite, BSN, RN]

Were you able to see the facility's care plan for this patient? Their care plan would probably explain the reason for the foley catheter since most LTCs are discouraged from placing foleys in their patients just because they are incontinent. My guess would be that the catheter is there because of incontinence and to help keep the skin and the decubitus on the coccyx from getting infected with bacteria from the urine. Were there any UA reports in his file? Does the patient have a chronic urinary infection where the bacteria in his urine might be in danger of contaminating any open skin wounds he might have?

Here are some nursing diagnoses I would suggest in order of priority:

1. Imbalanced Nutrition: less than body requirements R/T inability to absorb nutrients AEB slow wound healing (I'm not really good with nutrition, but in the nursing homes I've worked the dieticians were always having us call the doctors to get orders to put any patients with decubitus or healing wounds on Vitamin C, multivitamins and protein drinks several times a day to help with the wound healing.)
   
2. Impaired Skin Integrity R/T destruction of tissue and physical immobility [and probably altered circulation, as well] AEB [give your assessment data for the decubitus ulcer and skin here ]
   
3. Impaired Physical Mobility R/T imposed restrictions on movement and loss of motor control AEB [you're your assessment data here]
   
4. Acute Pain R/T destruction and interruption of skin and nerve structures AEB patient statements of pain or observed assessment of expressions indicating the patient is in pain
   
5. Risk for Infection R/T inadequate primary defenses and exposure to feces or urine [this would be where the foley catheter and it's care and maintenance would be addressed since you say the primary necrotizing fasciitis has been treated]

If you know, for sure that the foley catheter is for incontinence due to patient's inability to control his urine, you could use this nursing diagnosis:

• Total urinary incontinence R/T neurological dysfunction AEB constant and unaware flow of urine

[Medsport, LPN]

Thanks, I would have used imbalanced nutrition, but they took his g-tube out last week. We're not allowed to use the risk for yet. Also, I wonder if I should put Impaired Walking in there and if so should it go before Impaired physical mobility or after? Pain would then go 4th right?

[Daytonite, BSN, RN]

i'm going to go out on a limb here because i've worked in a long term care a lot over the years. he's got nutrition problems even though the g-tube was removed. with all the chronic conditions this fellow has, his body has been robbed of whatever nutrition he had by these various diseases. artificial tube feedings are no where near the quality of good hearty balanced meals that we eat--believe me. i'd be willing to bet that a nursing diagnosis addressing his nutrition was among the top two or three on his permanent care plan at this facility.

didn't you say this patient had contractures? is he even able to walk? impaired walking is usually used for someone who is able to move all other parts of their body, but only has some sort of problem with their legs such as an amputated limb, hip replacement, orthostatic hypotension, dvt, etc. they usually need assistive devices or assistive strategies of some type. if there are other problems with movement in the arms and back i wouldn't use this diagnosis. i would use the other diagnosis, impaired physical mobility.

pain is usually an issue of comfort and ranks last on the scale of physiological needs. the ranking according to maslow is in this order:

1. oxygen
   
2. food
   
3. elimination
   
4. temperature control
   
5. sex
   
6. movement
   
7. rest
   
8. comfort