i need one more diagnosis. i struggled with the first one.
ineffective peripheral tissue perfusion r/t tissue inflammation s/t cellulitis aeb pt stated tenderness in right lower leg, redness and warm to touch.
pt right lower leg will show signs of healing during my shift within 12 hours (decrease appearance of redness, swelling and pain in affected areas).
collaborate with the woc nurse for wound care plan.
nurse will elevate the pt's lower extremities on pillows above the heart level to decrease swelling.
reposition pt every 2 hours. offer pain medication at least 20 minutes before position change.
teach pt importance of proper nutrition in wound healing.
this is what was provided:
history and physical
date of admission: 2 days ago
attending physician: dr. pearla
chief complaint: chest pain
history of present illness and reason for admission:
this is an 80 yr old white female that was brought to er by paramedics. while at a family dinner she c/o chest pain, shortness of breath, weakness and dizziness. paramedics were called, ekg indicated possible acute mi. oxygen and nitro were given and pt. was transferred to the hospital.
she was also noted to have an open wound on her right lower leg, per patient it occurred last week when she fell in her bathroom. wound with purulent drainage and redness.
on routine tests pt. was found to be dehydrated. her blood sugar was elevated at 400 and also was diagnosed with cellulitis of right lower leg due to staph infection and was started on iv rocephin. iv fluids and insulin drip were started.
she was admitted to ccu.
past medical history:
1- diabetes type ii
3- coronary artery disease
4- frequent utis
1- appendectomy - 1956
social history: pt. is widowed, lives alone in a senior housing community. occasional smoker 1-2 per week. no alcohol. she has 2 daughters living in the area, both work full time. she admits to being non-compliant with her diet and forgetful with medications at times.
well developed obese elderly female, alert and oriented. vital signs: t= 100, p=90, r =20, bp= 150/88. pulse ox=95, weight= 190lbs, height= 5'2''. c/o 5/10 pain in her right lower leg. neck is supple, no jugular venous distention, no carotid bruit, no thyromegally. multiple bruises noted on the arms. right lower leg with an open wound with yellow discharge, area red, warm and tender to touch. lungs are clear to auscultation bilaterally, heart sounds indicates a murmur, rate at 90, regular rhythm; abdomen is soft with tenderness at suprapubic region with left cvat.
1- urine culture showed pseudomonas aeruginosa sensitive to gentamacin.
2- tissue culture showed staph aureus sensitive to amoxicillin so rocephin was discontinued and amoxicillin and gentamacin were started.
3- ekg with sinus tachycardia
4- bed side blood sugars were decreased to 120-130, so insulin drip was discontinued and placed on lantus insulin 20 units at bedtime and humalog 5-10 units pre-meals per sliding scale.
5- cbc- wbc: 13.5 ( 3.8-10.8) , hgb: 12.5 (11.7-15.5) , hct: 40.0 (35.0-45.0), platelates 284 ( 140-400)
6- bmp- glucose 160 (60-99) , bun 28 ( 7-25), creatinine 1.0 ( 0.60-1.18), gfr 45 ( >60), na 160 (135-146), k 4.9 ( 3.5-5.3), hga1c 11 ( <5.7)
1- htn-poorly controlled
2- s/p mi
3- dm ii- poorly controlled
4- cellulitis right lower leg
1- iv fluids
2- iv antibiotics
3- daily wound care
4- dietary evaluation- diabetic diet and nutrition education and weight loss
5- continue with current meds.
6- cardiac monitoring
7- cardiac rehab.
1- aspirin 81mg 1 tab po daily
2- lantus insulin 20 units qhs
3- humalog insulin 5-10 units ac meals per sliding scale
4- atenolol 50 mg po bid
5- gentamycin 1gm iv q12 hrs
6- amoxicillin 500mg iv q8 hrs
7- lisinopril 20 mg po daily
8- metformin 500mg po bid
Jan 10, '12
How about something to do with her risk for sepsis R/T multiple sources of infection (UTI and leg)?? Throw in her noncompliance with diabetes management, and you have the perfect storm for sepsis. Seriously, if she gets septic with her recent episodes of HTN, dehydration, and chest pains/possible MI, it could easily kill her. I would say that a nsg dx related to that would be of great importance. Interventions could include giving ABx doses on schedule, changing her Foley per the latest TJC guidelines for CAUTI (if applicable), and educating the patient on urinary and wound care. Who knows? Maybe no one has told her in the past to wipe from front to back...sometimes the simplest things escape us.
Jan 10, '12
let's look at this again.
"ineffective peripheral tissue perfusion this means, "there isn't enough blood flow in the leg...
r/t this means, "because she has ..."
tissue inflammation s/t cellulitis (i don't know what the abbreviation s/t means, but she has cellulitis, anyway)
aeb this means, "i know this because..."
pt stated tenderness in right lower leg, redness and warm to touch. "...she told me she has these symptoms."so, your working diagnosis is, "my patient has decreased blood flow in her leg because she has cellulitis with pain and tenderness and warmth." is that right?
i'm sorry, but that makes no sense to me at all.when i look in my nursing diagnosis book under "ineffective tissue perfusion," i don't see cellulitis, tenderness, redness, or warmth as defining characteristics. i do see delayed wound healing, but this is a fresh (1 week) wound and is infected, not merely colonized.
see, i think that what you have done is picked a diagnosis out of the air, not made one from your findings. many students do this-- they go about it backwards because they haven't got the idea of nursing as a separate, autonomous discipline (that's why you went to nursing school, believe it or not). how would you like a physician that says as soon as he walks in the room to see you the first time, before you tell him anything or he examines you at all, "you've got leukemia. now, i think we will check your blood work." you do your diagnostics first, so your diagnosis is based on something, not the other way around.
pt right lower leg will show signs of healing during my shift within 12 hours (decrease appearance of redness, swelling and pain in affected areas). (really? your said your diagnosis wasn't about wound healing, it's was decreased blood flow to tissues. so if that were so, your goal for that diagnosis would be to help address inadequate blood flow, see?)
collaborate with the woc nurse for wound care plan. how does collaborating c the woc nurse affect the patient's perfusion? (hint: it doesn't, not in the least) also, she does, in fact, need a wound care plan. you need to give your diagnosis about what she has that needs one, and why you know this to be true, find out what an appropriate wound care plan would be and put it in your care plan-- never turf off your job to someone else
:d but again.... this isn't really about perfusion, is it?
nurse will elevate the pt's lower extremities on pillows above the heart level to decrease swelling. (if she had inadequate blood flow,that's the last thing you would do-- elevating an ischemic leg makes it worse. fortunately for her, there's no evidence that she actually has decreased blood flow here. anybody check her pulses in her legs? capillary refill?
reposition pt every 2 hours. offer pain medication at least 20 minutes before position change. (she probably does have a pain problem. but dealing with it does not have anything to do with her perfusion. it's a separate diagnosis.)
teach pt importance of proper nutrition in wound healing." ((true that, but not much of a priority and nothing to do with your diagnosis of inadequate arterial blood flow, at least not as you have assessed it.)
your nursing care plan would be actions a nurse would do to address the causes of the problem. well, we don't know know whether she has ineffective perfusion, so there's nothing we can credibly do to help that problem. what we can do is look at her again and see what her diagnosis really is, and work from there.
starting over, then....
what are her medical problems? (i've given a list here)
what are the nursing problems? and how do you know? ( you figure out that part by assessing her, herself, not by reading her medical dx)
prioritize that list-- what's the one that is the most immediate threat to her? what's next? is she at risk for complications? which ones? what would a nurse do to head them off, or at least compensate for them? say why you know they are problems. for example, my patient has the nursing diagnosis of activity intolerance because she has ..... and i know this because she does ..... and she can't ..... to help her feel better or at least not make her feel worse because she has this problem, i will do these specific things which will directly affect the problem or how she deals with it: 1) 2) 3) 4).....
get the picture? that's what a nursing plan of care is: the nurse looks at the problems the patient has that can be diagnosed and treated by nursing. you do not know what the nursing dx is by knowing the medical diagnosis, you know from making a nursing assessment. you might use some of the same data that a physician uses to make a medical diagnosis, and it is assumed that you will carry out the medical plan of care, but this is not a nursing plan of care. if i admit a diabetic old lady with an mi and a cellulitis, i can have a pretty good idea of what her nursing diagnoses are gonna be, and what i would prescribe for them, but i can't make those diagnoses without doing the assessment of the patient myself; nursing diagnoses are based on my nursing assessment, and maybe they won't all be there
:d. my nursing plan of care doesn't include things like "give antibiotics as ordered, regulate ivs, diet low sodium" because those are part of the medical plan of care. but i might be on the lookout for nursing-determined interventions that are related to those.
if you don't have the nanda-i 2012-2014 book, you need it right away. really.
diabetes is not a nursing problem. but lots of things that happen to diabetics are.
mi is not a nursing problem, but its many effects are.
infection is not a nursing problem, but its effects are.
go forth. let us know your next ideas.
Jan 10, '12
I agree with GrnTea about your first nursing diagnosis...it's all skewed and mismatched, but not too horrible for a first try! :-)
But I DISAGREE with GrnTea about not including giving appropriate Abx on time on your care plan, for reasons below:
See this site for why I said Risk for Infection/Sepsis....and scroll down to the bottom where it lists Nursing Interventions associated with that diagnosis. One of the items is: ADMINISTER MEDICATIONS AS INDICATED (on page 5 of 13). This is a VERY important nursing intervention to the prevention of the spread or development of further infection.
lso, from your original post, it looks like you were not given a chance to actually assess the patient yourself, but given the lengthy list of what all is going on with the patient....several of the listed assessment details fall right into line with the criteria for a Risk for Sepsis nursing diagnosis.
AND, this site also lists "administer antimicrobials as ordered" as an appropriate nursing intervention for Risk for Infection: Sepsis nursing diagnosis:
EHS: Nursing Care Planning Guides - Care Planner: Diagnosis: Risk for infection: sepsis
Jan 11, '12
"as indicated" is not the same as "as ordered." the nurse should check the culture sensitivities to be sure the correct antibiotic is being prescribed before it's given. yes, that is a nursing responsibility. your nurse practice act says that you are legally bound to implement some aspects of the medical plan of care, medication administration among them, but that you are also legally bound to refuse or hold pending clarification an aspect that is not safe and appropriate.
my point was that parroting the medical plan of care, as many students and nurses do, is no substitute for a well-developed and -justified nursing plan of care.
Jan 12, '12
GrnTea -- can I hire you to move here to Las Vegas and be my personal live-in nursing tutor? I love all of your posts and learn so much. I have several bookmarked. I love you. :heartbeat
Jan 12, '12
ah, that is kind. :::looking for "blushing" smilie::: hitting the "like" button is good enough. :d
Jan 15, '12
hahaha! I think we r attending the same school. I have the same pt care plan and I worked on it like a mad person during break (x-mas holiday), but I think I got it right.
Sep 26, '14
GrnTea!! good work I like your comments....I am new to this website and wondering where I can view more of your postings.