Care plan help, please

[isis73]

Hi all,

I'm working on a care plan for my second week of clinicals this Thursday and Friday, and I could use some help prioritizing my top five diagnoses.

My pt has a G-tube, indwelling catheter, BKA and AKA, contractures in both arms, Alzheimer's, trouble swallowing (NPO), aphasia, Hx of DU (healed), rarely/never makes self understood, rarely/never understands others, upper respiratory infection, Hx of CVA, Diabetes Mellitus, peripheral vascular disease, SOB, and memory problem/no recall.

We are supposed to make our care plan based on the subjective data from the pt's chart, then revise it as needed after gathering objective data our first day of clinical.

So far, my top five (NUR 101 approved) diagnoses are:

1. Mobility: physical, impaired

2. Swallowing, impaired

3. Skin integrity, impaired

4. Self-care deficit

5. Urinary incontinence

Also, I can't use Self-care deficit this week as it was my priority diagnosis for my patient (different pt) last week.

Any help would be greatly appreciated--I really want to give my pt the best care possible this week.

Thanks!

Isis73

[Roseyposey]

that is true when the symptoms pertain to the airway. however, the nursing diagnosis, impaired swallowing, does not have anything directly to do with the airway. its definition is: "abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function." nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 195. nanda lists the causes (related factors) for it as being due to either congenital defects or neurological problems. a cva might create the neurological problem for the patient. while aspiration prevention is an outcome of this diagnosis, that does not establish it a topmost priority. in reality this nursing diagnosis would only be used if positive attempts were being made to feed the patient orally.

the nursing diagnoses dealing with airway obstruction, airway clearance and oxygenation that take often take priority over others are:

• impaired gas exchange
  
• ineffective breathing pattern
  
• ineffective airway clearance
  
• impaired spontaneous ventilation
  
• dysfunctional ventilatory weaning response

in maslow's hierachy of needs, the physiological needs are also arranged in priority. that priority is:

1. oxygenation (no oxygen getting to the brain or tissues leading to cell death)
   
2. food/nutrition
   
3. elimination
   
4. temperature control
   
5. sex/reproduction
   
6. movement
   
7. rest
   
8. comfort

when using nursing diagnoses you must always be familiar with the definition of the nursing diagnosis and the defining characteristics and related factors that nanda has approved as part of the descriptors for them. choosing nursing diagnoses is not something you can always do by looking at a list and picking out the ones that "seem" to fit your needs. that is not the intent of nanda or critical thinking at all! for this reason a nursing diagnosis book is much better for a beginner of care plan writing than someone who has been doing it for awhile and knows the signs, symptoms and causes of the various diagnoses. applying nursing diagnoses should be taken as seriously by nurses as physicians diagnosing medical conditions. physicians also have to learn the signs, symptoms and causes of many more diseases than the 172 current nursing diagnoses that nurses have to work with.

edited, never mind...

[Daytonite, BSN, RN]

honestly, it was a bit confusing to read your nursing diagnosis. i would start out by writing each r/t item on it's own line first. do the same with the amb items. because you have so many words here, i would suggest using semi-colons to separate each of these items when you write them out in the diagnostic statement. i can't tell the difference between what is separate from other things because of all the commas. i believe you have jumbled up r/t and amb items. you need to be very clear in your diagnostic statement in classifying which is which. my understanding of qualifying related factors of nursing diagnoses with "secondary to" items is to use medical diagnoses. am i right about that? if so, then you do not need to qualify moisture as a related factor with a "secondary to" of an assessment item. to me, wearing briefs is part of the assessment data and not a medical diagnosis. rather than saying hyperglycemia as a related factor, i would use altered metabolic state.

remember that your amb items support and relate back to the actual nursing diagnosis. what do an aka, bka and contractures have to do with skin integrity? they may contribute to the cause of the physical immobility, but they do not fit as symptoms, or defining characteristics (amb data), for this diagnosis. amb items would be things like description of actual skin breakdown or disruption that the patient has. the only thing you have listed that would qualify as an amb that i can see is "excoriation on sacrum/coccyx". as part of that description you should have taken some measurements of this excoriated area. if you have a nursing diagnosis book you need to look at the definition, defining characteristics and related factors for this specific nursing diagnosis to help you formulate this diagnostic statement.

i could not find anything on impaired skin integrity at the gulanick or ackley care plan constructor websites. however, i did find something on impaired tissue integrity which is a very, very similar nursing diagnosis on the ackely site:

http://www1.us.elsevierhealth.com/evolve/ackley/ndh6e/constructor/index.cfm?plan=49 - impaired tissue integrity

this is what my copy of nursing diagnoses: definitions & classification 2005-2006 published by nanda international has to say about the nursing diagnosis, impaired skin integrity, on page 175:

• "definition: altered epidermis and/or dermis.
  
• defining characteristics [these would be your amb items]: invasion of body structures, destruction of skin layers (dermis), disruption of skin surface (epidermis)
  
• related factors [these would be your r/t things]: external: hyperthermia or hypothermia, chemical substance, humidity, mechanical factors (e.g., shearing forces, pressure, restraint), physical immobilization, radiation, extremes in age, moisture, medications. internal: altered metabolic state, skeletal prominence, immunological deficit, developmental factors, altered sensation, altered nutritional state (e.g., obesity, emaciation), altered pigmentation, altered circulation, alterations in turgor (changes in elasticity), altered fluid status."

[isis73]

Skin integrity, impaired r/t physical immobility; altered circulation secondary to PVD; altered metabolic state secondary to DM; bowel incontinence and urinary incontinence AMB feeding tube, indwelling catheter and excoriation of sacrum/coccyx.

Better? (Yes, I am getting confused between what is a r/t and what is AMB--and secondary to does refer to the medical diagnosis) Thanks!

Isis73

[Daytonite, BSN, RN]

the feeding tube and indwelling catheter are not listed in such a way as to show any contribution to the diagnosis. items following your "amb" need to be abnormal assessment data items that help to describe the nursing diagnosis. just listing "feeding tube" and "indwelling catheter" does nothing to help describe any impaired skin integrity. what was abnormal about the feeding tube or indwelling catheter that was leading to impaired skin integrity. was there redness or irritation around the feeding tube? if so, then you need to state that because that is something that helps define impaired skin integrity. how was the indwelling catheter contributing to impaired skin integrity? was the urinary meatus red and irritated? was the tubing taped to the skin so that the skin was breaking down from the tape? was the patient lying on the foley tubing and getting skin breakdown from that? if so, then that needs to be listed as your amb item, not just the catheter. is that making sense to you when i put it that way?

to carry this further, when you continue onward to develop the nursing interventions for this nursing diagnosis, they will be aimed at the amb items in order to relieve and treat the impaired skin integrity. everything must follow a logical progression.