Care plan help please!

[NewNurse91D]

Hello All! =]

I'm doing my 2nd Med Surg care plan. & as always, I'm having some trouble connecting the dots & seeing all the pieces.

By no means, do I just want "answers". I would really appreciate a few ideas and some guidance; what do you guys see that I don't?

My pt: 63yo F. The day I had her, she'd been in the hospital for 10 days.

Admitting dx: Cellulitis of the R foot & septic shock.

Hx: DM (type 2), HTN, arthritis, GERD, hyperlipidemia, "COPD" (according to her, but not in chart). And she had cardiac bypass grafting done to 4 coronary arteries in '11.

Abnorm Labs: A1C 11.9- WBC 12.9- RBC 3.74- Na 133- Cl 96-Glucose 256- Albumin 3.2- MPV 9.6- Granulocytes 75.3- Eosinophil 0.3- Basophils 0.3.

& urinalysis: 3+ glucose, trace ketones, 1+ protein, 2.0 urobilinogen, "large amounts" of blood, 12 WBC, 8 RBC & "few" bacteria.

VS: 97.8 T, 20 R, 77 HR, 110/57 BP & apical HR 80. O2 is 99% on RA.

When I asked her to tell me about what happened- she told me she "stepped on a nail @ home BUT DIDN'T FEEL IT. and didn't know it was there until a family member saw the sore on her foot and said something to her" *

**So pausing right there: hx DM & HTN; glucose, ketones & protein in urine, A1C highhhh ANDDD she didn't NOT feel the nail go into her foot or the pain r/t it getting infected. I'm thinking some peripheral neuropathy and poor DM control, right?

***Another piece to that-her insulin regimen: Lantus 1x/day & 15-30u of Novolog for coverage. BUT she also receives 5u of Novolog routinely 3x/day. Which, to me, is another indication of poor DM control, right?

Picking back up from my assessment: LLE +1 non-pitting edema. L pedal pulse diminished but present. She had a cast/dressing on her R foot but R tibial pulse was present. Abdomen was soft and distended. I checked sensation in the L foot & it's diminished. She could "faintly" feel something. She c/o SOB and activity intolerance. I did a full head to toe assessment but besides what I listed-everything else was pretty uneventful (at least from what I see)

**Her albumin lab value also worries me, b/c that's r/t wound healing. & she is already impaired r/r the DM, HTN.

**She has a PICC line. & has had a CXR, CT of R foot, RLE venous Doppler. Along w/ a wound culture & an IND to the R foot.

Where do I go from here? I have all of this info but I feel like I'm missing something.

If you guys have any questions about her other labs, assessment data or the results of her tests please ask!

Thank you =]

[ashash1193]

Do you mean you are missing something in terms of finding nursing diagnosis?

[NewNurse91D]

I feel like I don't see my pt's 'bigger picture'. I also want to be able to do a good care plan focused on the big picture of my pt. I don't know where to start.

Do you mean you are missing something in terms of finding nursing diagnosis?

[JustBeachyNurse, LPN]

Start with the domains of NANDA-I nursing diagnosis and determine which domain(s) is relevant and a priority and which nursing diagnosis is priority. For example risk for infection is irrelevant at this point since she has an active infection. No respiratory complaints prevalent at this time.