Care plan help

Daytonite, BSN, RN · Mar 12, 2009

i can't help but notice that this patient has all kinds of heart related problems (cad htn, hyperlipidemia and was admitted for chest pain probably secondary to the cad) and yet you have no diagnoses addressing his heart situation. cad is a progressive degenerative disease that leads to multiple attacks of angina and eventually an mi. there should be a diagnosis of decreased cardiac output for this patient. his dvt of 2 months ago, is it because of a peripheral vascular problem? even if he is on blood thinners to prevent another dvt (those shots he refuses to give himself?) that is ineffective tissue perfusion, peripheral. is this man a smoker? is that why he has copd? what hypertension medications is he on? i think there are some more serious problems you missed.

activity intolerance r/t imbalance between oxygen supply and demand aeb dyspnea with exertion, increased heart rate with exertion, and patient reports needing multiple breaks when performing adls.
ineffective breathing pattern r/t respiratory muscle fatigue s/t copd aeb diminished lung sounds in all lobes, tripod positioning for breathing, labored, irregular respirations with pursed lip breathing, and dyspnea with exertion.
- the definition of this diagnosis is inspiration or expiration [the act of breathing] that does not provide adequate ventilation
- the patient's respiratory muscle fatigue is because of the constant coughing so the muscles are strained (have you ever had a cold and coughed so much your rib muscles got sore from the coughing? that is what is meant by "respiratory muscle fatigue"). it is not s/t copd.
- diminished lung sounds in all lobes and dyspnea with exertion is not proof, or evidence, that there is a problem with the act of breathing
- diminished lung sounds in all lobes is evidence of ineffective airway clearance and i would expect to see that in a copder along with dyspnea.

[*]acute pain r/t tissue inflammation s/t cellulitis aeb patient stated pain at 5/10 (lower left extremity, bilateral upper extremities and classified as constant throbbing), visible restlessness, and facial grimacing with extremity movement.

just say "aeb patient statement of constant throbbing pain of 5/10 in left extremity and bilateral upper extremities, restlessness, and facial grimacing with movement."

[*]impaired skin integrity r/t inflammatory response s/t cellulitis aeb local erythema and disruption of the dermis tissue, tenderness and pain at left lower extremity, bilateral upper extremities, and across entire chest.

when i read the aeb part of this diagnostic statement i should be reading the evidence that describes the impaired skin and form a picture of it in my mind. i don't know exactly how large all the areas are, what color they look like, if there is any drainage--nothing. you said in your post that it was itchy and swollen and none of that is even mentioned here. the 4 cardinal signs of inflammation are: redness, heat, swelling and pain. and inflammation is what caused this problem. when you include interventions for those things in your care plan they will sound disjointed and leave your instructor wondering why you included those types of interventions

[*]noncompliance r/t adherence to treatment plan aeb multiple hospitalizations within month due to reoccurrence of symptoms, pt unable to verbalize understanding of the necessity of treatment plan, and direct observation of patient's noncompliance with treatment plan (continually scratching rash areas).

the cause of the patient's noncompliance is not adherence to treatment plan. if they adhered to the treatment plan he probably wouldn't be in the hospital today. i don't personally like using this diagnosis and prefer using ineffective health maintenance instead because it allows for patients who marginally follow their plan of care. in that diagnosis, the related factors include cognitive impairments and poor coping skills which is pretty much what saying it is "annoying" to have to remember to take pills and give shots is without actually saying he's a jerk.
the aeb (evidence) of the problem is merely what you have that he fails to do to follow his plan of care and symptoms as a result. i would never say direct observation of patient's noncompliance with treatment plan. continually scratching rash areas is iffy too because the nurse should have given him an acceptable way to scratch at the itchy areas (yes, it can be done appropriately) and it looks to me like the nursing staff dropped the ball on assisting him with offering options on dealing with the itching.
my sils father is a sob (i don't mean short of breath). he is a terribly difficult patient to work with because he knows better than every one of his doctors. i can see where he would easily be labeled as noncompliant. yet, every time he gets sick, guess who is knocking on the door of the doctor's office? these people need to be in control. it's a behavior issue and it takes a lot of patience and finesse to work with them. personally, i think saying they are noncompliant is the wrong way to go. he dug his own grave when he knew better and didn't follow up on his cancer care and is now terminally ill and days away from dying with lung cancer. that was his choice. he was warned. a care plan is a mutual decision between the patient and the nurse. we don't have to agree with the doctor. there is no law that says that. we can support the patient even though we don't like it. all we need to do is find a happy medium to help the patient. then we have done our job.

runner125 · Mar 13, 2009

do you think decreased cardiac output would be a more appropriate #1 diagnosis? I was going back and forth between decreased cardiac output, ineffective breathing pattern (which looking back, is also addressed in activity intolerance), and impaired gas exchange. This guy obviously has respiratory/cardiac issues all around. He's on oxygen 2L via NC, and has to be continually reminded to keep NC on. even with the oxygen, he sats at around 92%.

Thanks for your help!

Daytonite, BSN, RN · Mar 13, 2009

A - B - C. Respiratory diagnoses go first. With all this reminding, is he forgetful or confused? Maybe he has oxygenation issues? Maybe he lost a few brain cells along the way with his angina which is a heart oxygenation issue and now he has some confusion.

runner125 · Mar 13, 2009

he's not forgetful or confused at all... like you said, he's just a control freak. he doesn't like having anyone tell him what to do. he resists anything the nurses tell him. i'm actually surprised he's even as mobile as he is, given everything he has... he even had an MI in 1996.

so activity intolerance would be #1 diagnosis, followed by a circulation diagnosis?

Daytonite, BSN, RN · Mar 13, 2009

I worked on a stepdown unit for many years. I know the type.

Ineffective Breathing Pattern or Activity Intolerance are in competition for priority. Activity Intolerance has elements of both respiratory and cardiac in it and really is about the person getting hypoxia although it focuses on the person getting fatigued. I was surprised that you didn't have Ineffective Airway Clearance. I would have made that #1 because if the airway isn't cleared so he can breathe the show is over (meaning the person doesn't get oxygen so they are in danger of dying faster).

runner125 · Mar 13, 2009

i was hesitant to use ineffective airway clearance because he didn't have any adventitious lung sounds, just diminished. obviously as a COPDer, he's prone to excessive secretions in general, I just didn't witness any issues with it when I took care of him.

Daytonite, BSN, RN · Mar 13, 2009

if you look at the defining characteristics for ineffective airway clearance in a diagnosis reference (they are listed on both these web pages: ineffective airway clearance and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=02) you will see that your patient does have two symptoms for it

diminished breath sounds in all lobes (this means he has secretions blocking his alveoli)
dyspnea

i might argue that absence of a cough is another. copders are almost constantly moving sputum out of their lungs or they are on their way to getting pneumonia or an atelectasis.

runner125 · Mar 13, 2009

I agree with you that the absence of a cough can be considered an ineffective cough since he really should be coughing. I witnessed his breathing treatment with RT and thought it was odd that he never coughed once. I discussed my care plan with my instructor today and have changed my diagnoses a bit:

Ineffective airway clearance R/T excessive secretions in lungs S/T COPD AEB diminished lung sounds in all lobes, irregular and labored respirations, and absence of cough

activity intolerance R/T imbalance between oxygen supply and demand AEB dyspnea with exertion, increased HR with exertion, and patient reports needing to multiple breaks when performing ADLs

Ineffective peripheral tissue perfusion R/T interruption of venous flow S/T bilateral DVT AEB capillary refill of 4sec, 1+ pedal pulses bilaterally, and mottling of skin on lower extremities bilaterally.

Impaired skin integrity R/T inflammatory response S/T cellulitis AEB local erythema, pruritus, and scant purulent drainage across entire left lower extremity and bilateral upper extremities, 2+ edema of LLE and 1+ bilateral upper extremities (still having difficulty describing this-- basically just red, hot, swollen, itchy all over with minimal drainage)

Ineffective health maintenance R/T ineffective individual coping AEB history of multiple hospitalizations within past month for persistence of symptoms, inability to verbalize understanding of treatment regimen, and statement of lack of interest in improving health behavior.

Does this sound better??

Daytonite, BSN, RN · Mar 14, 2009

It sounds great!