need help with CP/Dx

Nursing Students Student Assist

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I did a good job on my last care plan (that did'nt count), but my gf helped me quite a bit. Now I have one due on monday that is going to be counted and I can't figure it all out on my own. I've worked on it for 3 hours and still have'nt got all the prioritized list down, let alone the order. I know the air/breathing should go first, but I can't come up with 3 defining characteristics that we are supposed to have. (he's on 3L/min. of O2, but is not having difficulty breathing and I could'nt hear any lung abnormalties). So I skipped that one and went on to his bruised, reddened, discolored lower legs. I thought it would be impaired skin or tissue integrity or ineffective protection, but none of them completely fits, since the area is'nt exactly open, but very close to it with scaley skin, warm with edema. Do you guys think I should put something down for those or skip it if nothing fits? I do have about 6 Dx for the list out of about a dozen ineffective behaviors, but 3 of them have to do with self-care deficits. Some of the others have to do with dry skin, thinning, lifeless hair and poor tugur (which I can't find Dx for either, but I know they are probly not that important)

The patient has diabetes, CAD, PAD, DVT, renal failure, osteoarthritis, hypothyroidism, obesity, CSD, depression and AFib if that will help with any ideas where to go from here.

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Specializes in Med/Surg, Tele.

what was his meds, labs, was he in any pain, any other symptoms you assessed? . can you give us any more info, then just his medical diagnosises.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Medsport. . .your patient has 11 medical diagnoses! Do you mean to tell me that you didn't copy down any of the symptoms of these diseases from his history and physical exam in his chart?

Is the CSD celiac sprue disease?

I'm working on this.

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No, I did'nt copy down any symptoms, I did'nt think we were supposed to. We have some sheets to fill out that have physiological modes of expected behaviors and ineffective behaviors that we highlight while we're with the patient. We also do a physical assessment and do charting, but our instructor has'nt really gone into depth like other ins. on how to do the assessing. I dont know his labs, but vitals were PaO2 95, P 64, BP 98/62, R 20, T 97, blood glucose 111. Treatments: jobst stockings on at am, off at pm, elevate legs with pillows 3/day. Meds: Levothyroxine, Lexapro, Folic Acid, Amiodarone, Bumex, Lipitor, Prevacid. CSD is for cervical spine disease. He did'nt complain of any pain, but I did'nt ask him either. My gf got on my case about that. I told her nobody showed me how to do things, they just turned us loose, but she says you have to remember from your check-offs. I have so many of them that I forget if I don't do the procedure again within a few weeks. I did look up the diseases in my text and was trying to do the dx that way, but I guess you are supposed to use the nursing diagnosis book first. I'm trying, but there seems to be so much we have to know. I've been working on this and my next checkoff all day and have'nt even started studying for our lecture test monday...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

ok, here's a nursing diagnosis to get you started. don't know if you need to include "secondaries" in your diagnostic statements, but i included it just in case. i've also given you two websites where you can get nursing interventions.

  • ineffective tissue perfusion: peripheral r/t interruption of arterial flow aeb scaly skin on legs, edema of legs, reddened and discolored lower legs, and thinning hair over lower extremities, or
  • ineffective tissue perfusion: peripheral r/t interruption of arterial flow secondard to pad aeb scaly skin on legs, edema of legs, reddened and discolored lower legs, and thinning hair over lower extremities

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55

http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_072.php

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Yeah, I wanted to use Ineffective Tissue Perfusion for my dx, but the nursing dx book says, in Suggestions for Use, it is not recommended because renal tissue perfusion actually represents medical diagnosis and not nursing care, plus I don't have 3 defining characteristics that match...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

the breakdown in the tissue perfusion is in the guy's leg, not his kidney. i've given you 4 defining characteristics for ineffective peripheral tissue perfusion--the only abnormal data you really have. if you want to go strictly by nanda language the defining characteristics for peripheral would be:

  • edema
  • altered skin characteristics (hair, nails, moisture)
  • skin discolorations

you've got your three for this diagnosis. you should also be able to fit in the treatments and symptoms of his dvt into this diagnosis as well.

i'm looking at the symptoms of his other medical diagnoses. he's got oxygen going which is probably related to his cad or atrial fib. i'm guessing that he probably gets short of breath with any movement. dyspnea also shows up in the symptoms for cad and atrial fibrillation. you should be able to use a nursing diagnosis such as impaired gas exchange r/t alveolar-capillary membrane changes aeb dyspnea. your other defining characterisitics can be abnormal blood gases and you can also use skin pallor and/or abnormal breathing. there has to be a reason the doctor ordered oxygen for him.

i'm also thinking that he could get a diagnosis of decreased cardiac output since he's got atrial fib. it would be decreased cardiac output r/t altered electrical conduction aeb irregular heart rate, dyspnea and palpitations [if he has these, as they are symptoms of atrial fib]

in any case, here is the list of his diagnoses with symptoms for them. if any of the symptoms apply to this patient--use them to help support your nursing diagnoses.

diabetes (polyuria, polydipsia, nausea, anorexia, polyphagia, headaches, fatigue, lethargy, reduced energy levels, muscle cramps, irritability, vision changes, numbness and tingling in extremities, abdominal discomfort)

cad (angina, nausea and vomiting, cool extremities and pallor, diaphoresis from sympathetic stimulation , fatigue, dyspnea)

pad (decreased skin temperature, dry scaly shiny atrophic skin, hairless skin over lower extremity, dystrophic brittle toenails, rubor of skin when leg dependent or elevated)

dvt (pain, tenderness, fever, chills, edema of affected extremity, redness and warmth over affected area, palpable vein, lymphadenitis)

renal failure (weakness, fatigue, headaches, anorexia, nausea, vomiting, pruritis, polyuria, hypertension)

osteoarthritis (deep aching joint pain, stiffness in the morning, crepitus in the joints, altered gait, contractures, decreased range of motion, joint enlargement)

hypothyroidism (weakness, fatigue, forgetfulness, sensitivity to cold, constipation, unexplained weight gain, coorifice dry flaky skin, periorbital edema brittle nails, decreased cardiac output, slow pulse rate, poor peripheral circulation, congestive heart failure)

obesity

csd (cervical spine disease)

depression (sleep disturbance, appetite or weight change, attention or concentration problem, fatigue, reduction in pleasure or interest, feelings of guilt, suicidal thoughts)

atrial fib (dyspnea, dizziness, palpitations, exacerbation of congestive heart failure)

have you read over the information in these two stickys?

i don't know what your instructors are telling you, but the most practical thing you can do in terms of helping you with writing a care plan for any patient is to glean as much information from the patient's chart as you can get. that includes copying down signs and symptoms from the doctor's history and physical, any consultations, labwork results, evaluations by physical therapy, dietary, etc., results of x-rays and pathology reports. this is all assessment data. anything that is out of the norm is usable to support your nursing diagnostic statements as long as they are facts.

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Thanks, I totally missed the peripheral diagnosis in the book, I think that will work. Now I just have to pick the number 1 priority to do the care plan page. I believe the impaired tissue perfusion: peripheral will be it because of the oxygen circulation correct? But toileting self care deficit R/T impaired mobility status AEB requires assistance to go to bathroom, would be up there too...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Yes! Impaired tissue perfusion: peripheral will be #1 because of the oxygen circulation. The only thing that might trump it would be something like Decreased Cardiac Output depending on what makes up the components of it. If oxygen to the brain (as with an arrhythmia) is a concern, it bumps oxygen to the tissues of the leg, get it? Smart man!

Now, when you are looking at the self-care deficits think about what is going to happen if the patient gets no assistance at all with them. Nutrition is always going to be #1. No food, no life, you die. Nutrition (under Maslow) ranks second to oxygenation. I see most self-care deficits, however, falling under the area of comfort which is at the bottom of the list of physiological needs. And, among the ones you have, you can prioritize them within their own little group according to Maslow as well. Nutrition and feeding first, then elimination, then the hygiene ones (bathing, dressing).

You OK with this now? Do you think you understand where you are going with it? Hope you do an awesome job! This really is a kind of complex care plan because of the many problems this patient has. I wish wish you well.

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Specializes in Med/Surg, Tele.

Medsport,

don't get discouraged, I know , it is confusing to try to get everything together in nursing school. Daytonite is so nice and allways comes to the rescue , especially when it comes to careplans. Try to remember though, like she said , the next time when you prepare for a careplan, gather as many s/s and symptoms as you can about your patient. Not only the ones you assess, but also the ones you can find in the chart and nurses notes. From those and meds, labs, procedures, medical diagnoses you can usually come to a conclusion about a nursing diagnosis. On of our instructors told us also , when you have a nursing diagnosis , go back and look at your s/s and check to see if those match. I hope this makes some sense.

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