Nursing Diagnosis for Diabetic Foot Ulcer

[Norstar]

I'm a 3rd year nursing student and was wondering if I could get a bit of help with an assessment task I have. I have been asked to identify nursing diagnoses and rationales for a diabetic patient who was admitted for a foot ulcer debridement. The patient has an amputation from a previous ulcer and is known for his ill management of his condition. So far I have come up with the following;

Skin Integrity - due to immobilization & impaired circulation

Pain - associated with infection & surgery

Infection Risk - Immunocompromised patient; patient also is MRSA +ve

Self-Care Deficits - ill management of DM; delayed in seeking medical treatment

The patient also suffers depression and some nephropathy and has some complex social issues (single father etc) on top of having financial difficulties. I'm not sure if these extra issues need to be addressed with regard to his immediate condition in terms of nursing diagnoses. I realise they have an impact on his ADLs and have addressed this in a different section.

Any help would be greatly appreciated.

Thanks in advance!

Vanessa

[SuesquatchRN, BSN, RN]

I would due a risk for injury r/t lack of sensation in feet aeb numbness and tingling.

Also risk for infection r/t impaired skin integrity aeb big honkin' sore

MRSA doesn't mean immunocompromised.

[Daytonite, BSN, RN]

One of the reasons it is difficult for me to help you is because nursing diagnoses, like medical diagnoses, are based upon the symptoms a patient has. If you have a nursing diagnosis reference and look up the nursing diagnoses you have listed you will find symptoms (nanda calls them defining characteristics) listed for each of those nursing diagnoses. Your patient should have at least one or more of those symptoms (defining characteristics) in order for you to be able to use any particular diagnosis for the patient. If not, then you've diagnosed the patient incorrectly.

A diagnosis, any diagnosis, is the resulting decision or opinion after the process of examination or investigation of the facts. All kinds of professions perform the diagnosing of problems. That's just what you are doing--diagnosing problems that your patient has. The actual nursing diagnosis is nothing more than a label for the problem the patient is having. The first step in diagnosing is to perform a thorough assessment of the patient. [this is also the first step of the nursing process which is the problem solving process we nurses use.] this involves talking to the patient and going through a review of their history of symptoms as well as assessing their adls (activities of daily living). You also need to read the patient's medical record and perform your own physical assessment. From all that data that you collect you must compile a list of the abnormal data (symptoms) and make a nursing decision (nursing diagnosis). You have the nanda taxonomy (hopefully, a nursing diagnosis reference book) to help you pick nursing diagnoses that match with your abnormal data (symptoms).

So, what I'm saying is this. Knowing the patient's medical diagnoses just isn't very helpful in determining nursing diagnosis. It will help with understanding the underlying etiology of some of the patient's symptoms is all. However, what are your patient's specific symptoms? That is what is needed to correctly diagnose.

There are two diagnoses that are used with skin ulcers: impaired skin integrity and impaired tissue integrity. The use of either is dependent on the stage of an ulcer. Impaired skin integrity is for stage 1 and 2 ulcers; impaired tissue integrity is for the deeper stage 3 and 4 ulcers. Did you stage this patient's ulcer? Did someone else stage it? Do you have that information? You have to know that information in order to use the correct nursing diagnosis here.

I don't like the related factors you have attached to the self-care deficits. So, the reason the patient doesn't, let's say, dress or groom himself is because his diabetes is managed poorly and because he delayed seeking treatment for the diabetes? "because I didn't get insulin for my diabetes for a year, I can't dress myself properly, and I'm incontinent." does that make sense? It doesn't to me. If you look at a reference for these self-care deficits you won't find either of those related factors listed. The related factors listed for the self-care deficits revolve around the patient's physical, mental or physiological reasons for not being able to do their self-care. Note: you have got to use a nursing diagnosis reference book as a guideline to help you out when you are first learning to use these nursing diagnoses until you are confident in your ability to use and apply them to patient problems.

What are these complex social issues that the patient has? Did you use some sort of assessment tool to determine them? What specific financial problems are present? Does it involve obtaining medication, medical treatment, food, or housing? These are things you need to know to determine a proper nursing diagnosis. Remember to keep your eye on how finances relate to daily living needs. That's what we nurses do.

You said this patient had an amputation. I don't see anything pertaining to his mobility (ability to move around). Did you assess this? Is he using assistive devices? Is any kind of help needed with his ability to use these devices and move around? If so, this is a nursing problem and needs to be diagnosed and care planned for.

A patient's ill management of their condition requires some further investigation as to the underlying reasons for why. This is because there are several nursing diagnoses that apply to this and you need to make the appropriate assignment. It could be non-compliance, lack of knowledge or just plain orneriness.

What is going on with this patient's depression? Anxiety? Coping or self-esteem problems? Is he suicidal? Feeling isolated? Hopeless? Sad? These are things that have to be assessed for. The patient's depression can be a related factor (cause, etiology) for his self-care deficits [remember i said that they are physical, mental or physiological reasons].

What specific kind of infection is the patient at risk for? To us a "risk for" diagnosis you must have some condition in your mind that you think the patient will get in order to write the goals and nursing interventions. Also, "risk for" diagnoses are anticipated problems, not actual problems that the patient has. "risk for" diagnoses are of low priority on the care plan and are listed last. And while we're on "risk for" diagnoses, I would think this patient is a prime target for risk for falls if he has assistive devices, any peripheral neuropathy from the diabetes, uncontrolled blood sugars, visual problems, incontinence and the fact that he is an amputee.

Did I understand correctly that this patient already has mrsa and/or vre? If so, then he already has an infection and is no longer at risk for an infection! If this patient has mrsa or vre he already has an actual problem of an infection. For mrsa and vre you will need to list out the symptoms the patient has and match them to appropriate nursing diagnoses that will apply to them.

And, what did you assess with regard to this patient's diabetes situation? Are his blood sugars in control? In he on an appropriate diet? Is he following it at home? This may link in to his following a proper medical regime.

You will find information on care planning and choosing nursing diagnoses on this thread...

[Fiona59]

Don't know how drugs are paid for in Oz, but you might want to work up something about "lack of financial resources in paying for meds". Kind of go the social work consult route in regards to budgeting and social support in managing with a child as a single parent. Does he need homehelp or childcare?

[al7139, ASN, RN]

Think about how poorly managed diabetes impacts the body. High glucose levels in the bloodstream create poor circulation and vascular damage.

My main diagnosis for this would be: Inneffective tissue perfusion:peripheral r/t impaired arterial circulation aeb wound on foot.

Amy

[Daytonite, BSN, RN]

al7139 said:

Ineffective tissue perfusion, peripheral r/t impaired arterial circulation aeb wound on foot.

This 3-part nursing diagnosis is not constructed correctly.

First of all, the definition of this diagnosis is: decrease in oxygen resulting in the failure to nourish the tissues at the capillary level.

If you refer to a nursing diagnosis reference you will find that the related factors (etiology, or cause) for ineffective, or impaired, oxygen perfusion to the peripheral tissues must be something more specific than just "impaired arterial circulation." impaired arterial circulation is presumed to be present by the very nature of the nursing diagnosis (or problem) itself. Using the related factors is where some knowledge of the underlying pathophysiology of the patient's medical problem needs to be known. The related factors for peripheral ineffective tissue perfusion that nanda has listed in its taxonomy are:

• Altered affinity of hemoglobin for oxygen
• Decreased hemoglobin concentration in the blood
• Enzyme poisoning
• Exchange problems
• Hypoventilation
• Hypovolemia
• Hypervolemia
• Impaired transport of oxygen
• Interruption of blood flow [this would be a blockage of some sort]
• Mismatch of ventilation with blood flow

As for the aeb (symptom) part of the statement, a student really is expected to be much more specific. "wound on foot" needs to be fully described by listing its site, size (in mm/cm), presence of any drainage and it's color, type and amount. In this particular case, a wound should also be staged as being stage I, II, III, or IV. Additionally, a wound is not a defining characteristic (symptom) of this particular diagnosis, although "delayed healing" is. However, there must be evidence of delayed healing. As i noted above, a wound would require the use of the nursing diagnosis of impaired skin or tissue integrity for the problem of damaged skin/tissue because there are going to be extensive nursing interventions to treat it.

This is why I am always writing into almost every answer to a care plan or nursing diagnosis question that a nursing diagnosis reference should be consulted when first forming these nursing diagnostic statements until the criteria (causes and symptoms; nanda language--related factors and defining characteristics) for them are memorized and learned. Medical students do this until they learn all their medical diagnoses. We nurses should be no different in our care of working with and choosing nursing diagnoses.

Reference: page 228-9, Nanda-I Nursing Diagnoses: Definitions & Classification 2007-2008

[Norstar]

Thank you so much for your help everyone. It has really helped me to clarify exactly what a nursing diagnoses is and how to construct it and the related rationales. You have put in very detailed answers and it is very much appreciated. What an absolutely wonderful resource this forum is!!

Thanks again

Vanessa ?