Jump to content

Care plan help!

Posted

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Hello All!

I'm having some trouble connecting the dots & seeing all the pieces w/ my pt for this care plan. Im in med-surg 1. 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 =]

First off, some (some) nursing care plans will allow r/t medical diagnosis, but not everyone--so check.

Your nursing care plan would address other non-medical things (if that makes sense)

Alteration of health care maintenance, alteration in skin integrity, FALL RISK, discharge care plan. In the health maintenance, you can speak about education lapses in chronic health condition. In skin integrity how she is to function with movement and self care, fall risk due to alteration of sensation. Then your interventions could include education, resources, perhaps home health upon discharge, and whatever services in house she could get--pt/ot that type of thing.

The labs do suggest a chronic condition (or two or three!) however, your care plans need to reflect nursing care.

By the way...VERY impressive assessment! And that you have the ability to match assessment with labs and have a whole patient approach. Well done!!

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Thank you =] Im trying to connect the dots btwn the assessment & labs. And what do you mean by my "care plan would address other non-medical things"?

First off, some (some) nursing care plans will allow r/t medical diagnosis, but not everyone--so check.

Your nursing care plan would address other non-medical things (if that makes sense)

Alteration of health care maintenance, alteration in skin integrity, FALL RISK, discharge care plan. In the health maintenance, you can speak about education lapses in chronic health condition. In skin integrity how she is to function with movement and self care, fall risk due to alteration of sensation. Then your interventions could include education, resources, perhaps home health upon discharge, and whatever services in house she could get--pt/ot that type of thing.

The labs do suggest a chronic condition (or two or three!) however, your care plans need to reflect nursing care.

By the way...VERY impressive assessment! And that you have the ability to match assessment with labs and have a whole patient approach. Well done!!

Meaning that your care plan needs to reflect your nursing diagnosis and actions, not necessarily medical diagnosis and actions. And for your assessment, the things that you have pointed out are an amazing assessment, it points to some probable non-compliance, which would be the nursing diagnosis of "alteration of health care"--

In other words, you can not use medical diagnosis for a nursing diagnosis, only the result of said diagnosis....an MD would play with the meds to attempt to bring things into compliance, where you would use education, prevent falls due to sensory issues, that type of thing...

Best wishes

SopranoKris, BSN, RN

Specializes in Critical Care. Has 6 years experience.

What was her BUN, Creatinine & eGFR? I'd like to know her renal function, given all that blood in the UA. Did she have an ABG done? This would let you know if she had respiratory acidosis, which is typical with COPD patients (many are fully compensated, so don't be surprised if pH is normal)

Now, take all your assessment findings and make nursing diagnoses from what YOU see in your patient at this time. Just start listing them. As mentioned above, Fall Risk. Decreased sensory perception, self-care deficit, Pain, etc.

Once you have your list, then choose your priorities. Typically your ABCs + safety.

This should point you in the right direction. Don't get hung up on the medical diagnosis. What do you, as a nurse, need to focus on with this patient right now?

It is a fallacy that a nursing diagnosis cannot be related to a medical one. A common fallacy, but a fallacy nevertheless. dedidier has already learned that. :) Anyone who doubts it should flip through the NANDA-I 201502017 and see how many nursing diagnoses have causative/related factors that are medical diagnoses. The confusion is often related to the fact that a nursing plan of care ought not to be full of medical plan of care interventions; we do those anyway. What NURSING is indicated for someone like this? That's the question this assignment is asking.

dedidier, you have already demonstrated good assessment and planning skills, and you know that your nursing plan of care will be aimed at prescribing nursing interventions for you to either implement or delegate. Step back and look at this person. What does she need, according to your assessment? Personally, I don't think you're missing much at all, for a first go-round. Why do you think you're missing something?

You have her obvious lack of understanding about diabetic neuropathy (and other effects of DM?) and what kind of trouble she can get into with it

You have her lousy healing (and her increased risk of further injury) r/t her DM/peripheral vascular insufficiency; you know that low serum proteins can make it harder to heal a wound, but also, for her, her DM, high glucoses, and lousy capillary flow are even more significant

You know that CV disease is rampant in DM; relate that to her SOB and activity intolerance much?

She already has an infection. What happens if it spreads/seeds elsewhere?

What do you need to think about for when she goes home?

We do not use the word "compliance" at all. One complies with an order, and there are no orders in our field. There are prescriptions, from many professionals --physicians, nurses, therapists, dentists, and others -- and the patient always has the choice to adhere or not to adhere to them. The patient is not obliged to comply with an order, as there is no such hierarchy in the patient/caregiver relationship.

So ... where do you go from here, other than implementing the parts of the medical plan of care we're obligated to do anyway and which don't appear in a nursing plan of care unless there are prns dictated by nursing assessment (like sliding scale)?

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Her BUN was 11, creatinine 0.9 & gfr >60.

She didn't have any ABG's done =/

I feel like the big things to focus on for my pt. are infection management, nutrition (albumin), DM education, tissue/skin integrity mainatance.

What was her BUN, Creatinine & eGFR? I'd like to know her renal function, given all that blood in the UA. Did she have an ABG done? This would let you know if she had respiratory acidosis, which is typical with COPD patients (many are fully compensated, so don't be surprised if pH is normal)

Now, take all your assessment findings and make nursing diagnoses from what YOU see in your patient at this time. Just start listing them. As mentioned above, Fall Risk. Decreased sensory perception, self-care deficit, Pain, etc.

Once you have your list, then choose your priorities. Typically your ABCs + safety.

This should point you in the right direction. Don't get hung up on the medical diagnosis. What do you, as a nurse, need to focus on with this patient right now?

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Thank you =] good to see you on my post!

& I feel like I'm missing something because I don't really know what to DO about it.

I think I see the some of the big picture- poor DM control (A1C lab), diabetic neuropathy (didn't feel nail or pain upon or after injury), poor wound healing (r/t albumin, DM and CV disease), I don't think my pt. is really 'following' her health plan or care for DM. I think she also has a big risk for that foot being amputated.

And yes, the SOB and activity intolerance deff correlate to the CV disease as well as the COPD.

She was admin. for septic shock, so she could die is the infection got worse or wasn't able to be cleared up.

What can I do about the above issues? education, antibiotics, nutrition...but I kind of run blank after those things.

I'm remembering the advice that you and the other's gave me on the last care plan =] so im starting w/ my assessment/data-figuring out what I, the NURSE, can do about it-THEN choosing a dx based on that.

It is a fallacy that a nursing diagnosis cannot be related to a medical one. A common fallacy, but a fallacy nevertheless. dedidier has already learned that. :) Anyone who doubts it should flip through the NANDA-I 201502017 and see how many nursing diagnoses have causative/related factors that are medical diagnoses. The confusion is often related to the fact that a nursing plan of care ought not to be full of medical plan of care interventions; we do those anyway. What NURSING is indicated for someone like this? That's the question this assignment is asking.

dedidier, you have already demonstrated good assessment and planning skills, and you know that your nursing plan of care will be aimed at prescribing nursing interventions for you to either implement or delegate. Step back and look at this person. What does she need, according to your assessment? Personally, I don't think you're missing much at all, for a first go-round. Why do you think you're missing something?

You have her obvious lack of understanding about diabetic neuropathy (and other effects of DM?) and what kind of trouble she can get into with it

You have her lousy healing (and her increased risk of further injury) r/t her DM/peripheral vascular insufficiency; you know that low serum proteins can make it harder to heal a wound, but also, for her, her DM, high glucoses, and lousy capillary flow are even more significant

You know that CV disease is rampant in DM; relate that to her SOB and activity intolerance much?

She already has an infection. What happens if it spreads/seeds elsewhere?

What do you need to think about for when she goes home?

We do not use the word "compliance" at all. One complies with an order, and there are no orders in our field. There are prescriptions, from many professionals --physicians, nurses, therapists, dentists, and others -- and the patient always has the choice to adhere or not to adhere to them. The patient is not obliged to comply with an order, as there is no such hierarchy in the patient/caregiver relationship.

So ... where do you go from here, other than implementing the parts of the medical plan of care we're obligated to do anyway and which don't appear in a nursing plan of care unless there are prns dictated by nursing assessment (like sliding scale)?

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

I am a little confused on the urinalysis results though. I mean her urinalysis was HORRIBLE. and this may be a dumb question-but why was it SO bad? Can septic & poorly managed DM cause that?

I also have a question r/t one of her radiology tests done. It said that it was a "Chest XR PA/LAT" What is the PA and LAT? are they like the two different parts that they viewed? The report was "minor bibasilar atelectasis". SO she has atelectasis bilaterally in the bases, is that from the COPD, from being immobile in the hospital for the past 10+ days? Can I address that in my care plan, b/c I feel like she is at a very high risk for other infections right now r/t the septic and atelectasis is a straight shot to pneumonia.

It is a fallacy that a nursing diagnosis cannot be related to a medical one. A common fallacy, but a fallacy nevertheless. dedidier has already learned that. :) Anyone who doubts it should flip through the NANDA-I 201502017 and see how many nursing diagnoses have causative/related factors that are medical diagnoses. The confusion is often related to the fact that a nursing plan of care ought not to be full of medical plan of care interventions; we do those anyway. What NURSING is indicated for someone like this? That's the question this assignment is asking.

dedidier, you have already demonstrated good assessment and planning skills, and you know that your nursing plan of care will be aimed at prescribing nursing interventions for you to either implement or delegate. Step back and look at this person. What does she need, according to your assessment? Personally, I don't think you're missing much at all, for a first go-round. Why do you think you're missing something?

You have her obvious lack of understanding about diabetic neuropathy (and other effects of DM?) and what kind of trouble she can get into with it

You have her lousy healing (and her increased risk of further injury) r/t her DM/peripheral vascular insufficiency; you know that low serum proteins can make it harder to heal a wound, but also, for her, her DM, high glucoses, and lousy capillary flow are even more significant

You know that CV disease is rampant in DM; relate that to her SOB and activity intolerance much?

She already has an infection. What happens if it spreads/seeds elsewhere?

What do you need to think about for when she goes home?

We do not use the word "compliance" at all. One complies with an order, and there are no orders in our field. There are prescriptions, from many professionals --physicians, nurses, therapists, dentists, and others -- and the patient always has the choice to adhere or not to adhere to them. The patient is not obliged to comply with an order, as there is no such hierarchy in the patient/caregiver relationship.

So ... where do you go from here, other than implementing the parts of the medical plan of care we're obligated to do anyway and which don't appear in a nursing plan of care unless there are prns dictated by nursing assessment (like sliding scale)?

la_chica_suerte85, BSN, RN

Specializes in Pediatric Hematology/Oncology.

Why do you think her UA was such a mess?

I, personally, am blown away by your assessment. You should seriously pat yourself on the back. You are a rare one.

My opinion of her UA is that it largely is d/t her DM being so poorly controlled. She may have a UTI AEB the WBCs and, if she had a urinary catheter that may be why there were "gross" amounts of blood in the urine.

I think in terms of her situation, she has no control of her chronic problems whatsoever. Based on the picture you painted her, I would agree with the alteration of health care maintenance, skin integrity, etc. You're getting the pt 10 days after her initial admission. It's clear that she's stable (that's kind of the only thing I'm missing from the assessment is her LOC and how easy she is to talk to) and needs a lot of help while she's there.

There were some things that I couldn't place well based on your assessment, however. I have some questions that might point to where you are feeling things are missing.

How is her pain with the cellulitis? I can't imagine even 10 days later that she would be feeling even remotely better with how poorly she is healing d/t the DM. I would want to try to get this pt to do some form of physical activity and gauge her motivation to do so. How is her diet while in the hospital? Does her family bring her foods contraindicated to her diet? What is her social support system like? In terms of her insulin regimen, ask her what her goals are in terms of what she would like. Pts all too often accept that they don't really have a choice and if they have to go on more insulin there is nothing they can do about it. It's doubtful anyone would want to have to take insulin that frequently but you can segue this into your education planning.

I would look at pain control, skin integrity, readiness for enhanced knowledge, alterations in health maintenance, etc., etc.

It looks like you're on the right path!

The PA/LAT is the positioning and views. The PA is posterioanterior view (the xray is taken from the person's back as it is much clearer than an anteriorposterior - an AP is reserved for people who can't stand) and LAT is for the lateral sides being radiographed.

You're not expected to cure her many medical problems. :) I don't know about your program, but mine stopped issuing magic wands and crystal balls when they decertified from the Rowling Division years ago. ;)

If you can find out why she is having such a hard time taking better care of herself, including whether she has access to learning opportunities and support, you'd be on the path.

But don't make yourself nuts not being able to do more than you can. You have the makings of an excellent plan here. Just do it.

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Thank you :) that's a huge compliment! and she is A&O x4, very easy to talk to. She acknowledges what's going on with her health but it seems like she doesn't acknowledge what's causing it. She is in a great deal of pain, like you said r/t the DM and the poor wound healing. He husband brought her in some juice and kfc for dinner -_- so I'm deff thinking that she obviously isn't followng Her diet. She is mobile; besides her foot and pain-she can walk and move around without difficulty.

I was thinking that the urinealysis was kinda of result of a two different 'beasts'. First-DM poor management and Second-septic shock.

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Your right :) hahaha thank you! I feel better now, I'm once again making it so much more complicated lol

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 10 years experience.

What can I do about the above issues? education, antibiotics, nutrition...but I kind of run blank after those things.

Good start. Think about the atelectasis and the activity intolerance, too. Don't forget about pain. There are a few more things you can do if you think about nursing interventions associated with those findings.

la_chica_suerte85, BSN, RN

Specializes in Pediatric Hematology/Oncology.

Thank you :) that's a huge compliment! and she is A&O x4, very easy to talk to. She acknowledges what's going on with her health but it seems like she doesn't acknowledge what's causing it. She is in a great deal of pain, like you said r/t the DM and the poor wound healing. He husband brought her in some juice and kfc for dinner -_- so I'm deff thinking that she obviously isn't followng Her diet. She is mobile; besides her foot and pain-she can walk and move around without difficulty.

I was thinking that the urinealysis was kinda of result of a two different 'beasts'. First-DM poor management and Second-septic shock.

I would then start with managing her pain and getting her to ambulate (see the issue of atelectasis above). So, Dx of acute pain and impaired walking. Then, for a psychosocial (my program requires 2 physio and 1 psychosocial Dx per care plan), deficient knowledge. That's what kind of care plan you could do for her in that shift. She really needs to be able to move around, even with the cellulitis (it's not fun, it's not pretty, it hurts like holy heck, but it's necessary. Easing her pain prior to that should help somewhat but this should be a lesson for her that if she was to get her DM under better control, things would really start feeling better. You can converse with her regarding her situation on being insulin-dependent. I mean, I guess that's what I would do. But otherwise, you've pretty much got it. Don't over-think it!! You got this! Good luck! :)

SopranoKris, BSN, RN

Specializes in Critical Care. Has 6 years experience.

It is a fallacy that a nursing diagnosis cannot be related to a medical one. A common fallacy, but a fallacy nevertheless.

I absolutely agree. However, when I help lower level students with care plans, they tend to get so hung up over the medical diagnoses that they forget pertinent nursing diagnoses. But you're 100% correct :)

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Okay thank you =]

Good start. Think about the atelectasis and the activity intolerance, too. Don't forget about pain. There are a few more things you can do if you think about nursing interventions associated with those findings.

NewNurse91D

Specializes in Geriatrics, In-Home Care, Community Based Nursing. Has 2 years experience.

Thank you very much for your helpful advice! =]

I would then start with managing her pain and getting her to ambulate (see the issue of atelectasis above). So, Dx of acute pain and impaired walking. Then, for a psychosocial (my program requires 2 physio and 1 psychosocial Dx per care plan), deficient knowledge. That's what kind of care plan you could do for her in that shift. She really needs to be able to move around, even with the cellulitis (it's not fun, it's not pretty, it hurts like holy heck, but it's necessary. Easing her pain prior to that should help somewhat but this should be a lesson for her that if she was to get her DM under better control, things would really start feeling better. You can converse with her regarding her situation on being insulin-dependent. I mean, I guess that's what I would do. But otherwise, you've pretty much got it. Don't over-think it!! You got this! Good luck! :)