Care plan help, please?

Carpediem1012, BSN, RN · Sep 24, 2014

Think about her ABCs

Wave Watcher · Sep 25, 2014

You said she was a non compliant diabetic by evidence of 2 glucose readings over 300 in one shift. Have you checked her A1C? Do you have other evidence to prove she is non compliant? Could it be underlying issues such as medications, steroids, stress, inactivity, other chronic disease process causing increase in BS? Does she take her insulin therapy? What does she eat during the day? Just a thought on the diabetic statements. :-)

Esme12, ASN, BSN, RN · Sep 25, 2014

Care plans are all about the assessment...of the patient. 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.

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.

Now tell me your assessment of your patient....what could possibly be MORE important

Risk for falls, RT dressings on feet, use of walker, and decreased LE strength
Risk for infection RT open wounds on legs and feet on an ambulatory patient
Inneffective tissue perfusion, RT DMII AEB Slow healing to lesions on LE.

given the information you already have given?

She is a non-compliant diabetic (BG 300+ both times this shift), but her HTN appears controlled, since I was unable to give her digoxin and metoprolol, due to her BP and pulse being too low. She has a trach, but has sats in the 90+% range without her collar on. She currently has round lesions down both LE, with open wounds around both feet that are moist, but have scant, clear to yellow discharge.

Have you looked up Leukocytoclastic Vasculitis

RevRacer · Sep 27, 2014

You said she was a non compliant diabetic by evidence of 2 glucose readings over 300 in one shift. Have you checked her A1C? Do you have other evidence to prove she is non compliant? Could it be underlying issues such as medications, steroids, stress, inactivity, other chronic disease process causing increase in BS? Does she take her insulin therapy? What does she eat during the day? Just a thought on the diabetic statements. :-)

My apologies. She is compliant when we giver her insulin, but her blood glucose levels are usually between 300 and 400, both from my measurements, as well as from the hx provided by the nurses on the floor. She keeps fruit juice in her room, and says she has to have it, even though she has been educated multiple times. Unfortunately, I am no longer at that facility, and I had an unintentional ignorant moment and did not take note of the a1c in her lab results. She is under increased stress, given her rash, open wounds, and time in the hospital. I didn't have any steroids ordered, other than triamcinolone cream that the MD told her not to use during his rounds while I was there. She eats what is on the tray, but the dietary group in that facility does their diabetic diets based soley on carbs, and pays no mind to having things like sugar packets, crackers, and fruit on her tray. Rather than request something that wont send her sugar sky high, she eats right on, and isn't surprised in the least when she sees those BG readings. She's also got some pretty interesting things in her urine - with a trace of blood, 3+ glucose, 1+ leukocytes, and even a trace of protein in there. I'd say there are likely multiple issues that I wasn't made aware of in the short time I had her as my patient.

Care plans are all about the assessment...of the patient. 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.
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.

Now tell me your assessment of your patient....what could possibly be MORE important given the information you already have given?Have you looked up Leukocytoclastic Vasculitis

I skimmed through it briefly when I was in clinical, but upon looking at it deeper, it's really something that is rather intriguing. I also realized that I never asked what brought about the trach. Her doctor had her come off her allopurinol for her gout, as he thought it was the cause for the LCV. He has since put her back on it. As far as her assessment, her BP and HR were 110/53 and 47, respectively. I saw no information on cardiomegaly, and she showed no signs of duress, dyspnea, or drowsiness, other than hurting too much to sleep the night before. Her low HR was common for her, per the nurses on the floor. Her blood sugar, along with the UA results that I showed in my previous reply really concerned me. Her H&H was rather low as well, at 33/10.4. She also showed low sodium (133) high potassium (5.9), and her creatnine and BUN were out of whack too (2.4/82). Further blood values of note were MCHC of 31, MPV of 10.7, Neu's at 87. Lymphs at 10, and Eosin's at 0. She had cap refill

I feel that she is at severe risk for a systemic infection, between her open wounds, the nature of LCV, and her uncontrolled DM. My own personal opinion is that she should be evaluated for other bleeding with her blood values as they are, and her liver kept an eye on. She was on the contact list for the wound center at that facility, which is one of the best in the area. I am unsure if they were able to consult, and what direction they decided to take.

Hope this helps!

-Michael

Esme12, ASN, BSN, RN · Sep 27, 2014

I'm confused...what do you mean by a process recording. I thought that was a conversation recording of patient and nurse interactions. Is this more of a case study?

RevRacer · Sep 28, 2014

They call it a process recording, but its basically a huge care plan... We have an Interpersonal Process Recording that's more what you're thinking of.

Esme12, ASN, BSN, RN · Sep 28, 2014

non-compliant diabetic (BG 300+ both times this shift)
BP and pulse being too low.
has a trach
round lesions down both LE, with open wounds around both feet that are moist
glucose levels are usually between 300 and 400
keeps fruit juice in her room
hurting too much to sleep the night before
low sodium (133) high potassium (5.9), and her creatnine and BUN were out of whack too (2.4/82)
H&H was rather low as well, at 33/10.4

Now looking at what you provided I can see plenty of possible nursing diagnosis that apply to this patient. what semester are you? What care plan resource do you use?

Is she overweight? How did her lungs sound? Did she have excessive secretions? Does she have A FOLEY? Why was this patient admitted? What meds is she on?