Nursing diagnosis for pt w/ fungal infection of toenails?

  1. My pt (65 yr/ w/f) has grossly malformed, crusty,yellow toenails that are obviously suffering from a fungal infection. Pt said that her doctor told her that there was nothing that he could do to treat the infection. I asked her if she'd been prescribed a pill to take for them, or a cream, and she said no. She is Type 2 Diabetic, and visits an orthopedist "every couple of months" to cut and file her toenails and he "files them down to almost look normal." I asked her if the orthopedist had attempted to treat the infection and she replied no.
    I am at a loss! Not only was I concerned about her nails, I can not come up with a NANDA nursing diagnosis for this! I had this pt in clinicals, so cannot follow up with her or her doctor, as much as I'd like to. Please help? Any suggestions would be appreciated.
  2. Visit c.bridges profile page

    About c.bridges

    Joined: Dec '12; Posts: 2


  3. by   Esme12
    Welcome to AN! The largest online nursing community!!!

    Is this the most pressing issue for this patient? Is this the first priority? I appreciate that diabetics require meticulous foot care but is this why the patient was in the hospital? Just because it grosses you out....doesn't make it a priority.... . What else could poor hygiene/self neglect/self care deficit indicate? What else can make her nails so think and yellow?

    What semester are you? Many students have difficulty finding the priority....tell me about your patient? My general advice......

    Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? Again........TELL ME ABOUT YOUR PATIENT... what care plan book do you use.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1.

    Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

    What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

    Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    I am willing to help ........So tell me about your patient...... What are the vitals? What is YOUR assessment of the patient? What do the complain of????

    What is this patients story......TELL ME ABOUT YOUR PATIENT.

    What care plan book do you use? Having a good cage plan book and/or a nursing diagnosis book is essential to do care plans. Here is a list of the NANDA diagnosis provided by VickyRN asst admin.
    Nursing Diagnoses 2012 - 2014.pdf‎ (35.7 KB, 3833 views)

    Here are some brain sheets made by another contributor Daytonite (RIP) for you next care plan.
    critical thinking flow sheet for nursing students
    student clinical report sheet for one patient
  4. by   c.bridges
    The pts vitals were normal and stable for her condition (taking her baseline into account, of course). I have already formed several other nursing diagnoses, related to the cellulitis that she was admitted for, as well as skin lesions I found on her back that are suspicious. We are instructed to find ten different, separate nursing diagnoses for each patient in our care, and I saw this as not the most serious problem, but still one that needed to be addressed. By the way, I appreciate your lengthy,thoughtful answer, and had already read it on another post on here...I've been reading most of the night on this site!
    So....I am still stumped as to what to do about a nursing diagnoses for this fungal infection. I wasn't "grossed out" at all, it takes alot more than that actually! I even gave her a massaging foot bath as part of my care for her that day, in full and close contact with said "gross" toenails, haha. I feel for this patient, though, and would like to know what to do if I run into this situation again.

    Any diagnosis ideas? I did teach the patient, on several topics, including her lesions that needed to be examined immediately, and her diabetic diet as well. I have Readiness for enhanced self-health management as one of my diagnoses. I just simply do not know what to do about the toenail issue. Risk for infection seemed to not fit, because she already has the infection. I'm at a loss! I appreciate any and all help you could give me on this.

    P.S. I use Ackley's Nursing Diagnosis Handbook, 9th edition as well as it' online component.
    Last edit by c.bridges on Dec 5, '12 : Reason: Adding an answer to a question
  5. by   Esme12
    I use Ackley's as well.....I paste and copy my usual assist speech for as a new poster I have no idea if you have read here, lurked here, what semester you are.............I gave you some ideas in my first post right from Ackley...
    What else could poor hygiene/self neglect/self care deficit indicate? What else can make her nails so think and yellow?
    Some other that could apply......
    Deficient Knowledge (specify)
    Chronic low Self-esteem
    Bathing Self-Care deficit
    Impaired Skin integrity