Care plan help!

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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 =]

Specializes in Geriatrics, In-Home Care, Community Based Nursing.

We can only have 2 dx =/ and my last care plan was really good but my instructor saw that I had a big problem with condensing stuff and she noticed that im trying to do TOO much, making everything too wordy and too long. and yes I deff think that if she took better care of herself and her health than this whole thing wouldnt have happened to her. which tells me that's priority?

Is there some reason you're limited to one or two? If you are, justify your priorities. Learning to do that is part of your education too.

Finally, if she (and her husband! He counts too!) had a better handle on her self-care, is there a chance she wouldn't be in this mess in the first case?

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

ahhhh I see. okay I have a hard time picturing the cardiac stuff. I can picture respiratory, endocrine, GI, etc BUTTT cardiac is very unfathomable to me. I mean its SOOOOO big and effected by everything and every body system lol. DM increases that resistance and over time the heart would just stop when it couldn't do anymore?

High BP doesn't necessarily lower CO. When you exercise, your blood pressure goes up because your body needs a bigger cardiac output. Chronic high blood pressure makes the myocardium grow, as with any muscle that works hard.

So ask yourself about the effect of long term increased resistance as a cause for this, and what happens sat the point when the myocardium just can't do it anymore.

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What I mean is, it's too simplistic (to the point of meaningless) to say, "High blood pressure lowers cardiac output."

High systolic and diastolic blood pressure can happen as consequences of high cardiac output due to increased contractility. It's supposed to do that sometimes.

High diastolic blood pressure means the ventricle has to push harder to open the aortic valve when it contracts to make systole.

Someone with longstanding high blood pressure is beating on his kidneys, his myocardium, his cerebral vessels, and this will make all of those wear out or break sooner.

If peripheral vascular resistance increases enough (beyond what would be a good idea to maintain BP in hypovolemia, say) then the heart can fail because it just can't push that hard, and then CO will fall due to the heart failure.

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

OH okay. You explained that very well, thank you. You are really smart! What type of nurse are you? Like, ICU/ER, Med-surg, etc? And how do you stay up-to-date on all of the information/news in the nursing world? Conferences?

What I mean is, it's too simplistic (to the point of meaningless) to say, "High blood pressure lowers cardiac output."

High systolic and diastolic blood pressure can happen as consequences of high cardiac output due to increased contractility. It's supposed to do that sometimes.

High diastolic blood pressure means the ventricle has to push harder to open the aortic valve when it contracts to make systole.

Someone with longstanding high blood pressure is beating on his kidneys, his myocardium, his cerebral vessels, and this will make all of those wear out or break sooner.

If peripheral vascular resistance increases enough (beyond what would be a good idea to maintain BP in hypovolemia, say) then the heart can fail because it just can't push that hard, and then CO will fall due to the heart failure.

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

OKAY guys!

So I have narrowed it down! (about time -_-)

But I have narrowed it down to three dx... lol

I have my 2nd one good and solid but my first one is a little harder because I don't know which one is more appropriate.

Im stuck btwn:

1A. Activity Intolerance r/t cellulitis of R foot and septic shock.

1B. Impaired skin Integrity r/t cellulitis of R foot secondary to poor DM management.

And

2. Ineffective Self-health management r/t Ineffective self-care practices and patterns regarding both the short & long-term maintenance control of DM.

*I know my r/t part is VERY wordy, I'm still working on my wording of it =/

My thought process: 1A (activity intolerance) is good b/c I can address the atelectasis, issues r/t her wound, pain, preventing DVT/clots, antibiotics etc.

But w/ 1B (impaired skin integrity), I feel like it's more fitted for her and I might have a little more information to 'back it up'. BUTTTT I can't address the atelectasis and activity intolerance in it =/ which I feel like is a big deal.

I don't know if im explaining what im trying to say right, but I'm wondering if this is one of those 'nursing decision points' and prioritization?

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

there is also an "impaired physical mobility" dx which MIGHT be what i'm looking for. hmmmmm

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Im stuck btwn:

1A. Activity Intolerance r/t cellulitis of R foot and septic shock.

1B. Impaired skin Integrity r/t cellulitis of R foot secondary to poor DM management.

And

2. Ineffective Self-health management r/t Ineffective self-care practices and patterns regarding both the short & long-term maintenance control of DM.

*I know my r/t part is VERY wordy, I'm still working on my wording of it =/

My thought process: 1A (activity intolerance) is good b/c I can address the atelectasis, issues r/t her wound, pain, preventing DVT/clots, antibiotics etc.

But w/ 1B (impaired skin integrity), I feel like it's more fitted for her and I might have a little more information to 'back it up'. BUTTTT I can't address the atelectasis and activity intolerance in it =/ which I feel like is a big deal.

I don't know if im explaining what im trying to say right, but I'm wondering if this is one of those 'nursing decision points' and prioritization?

In the NANDA-I 2015-2017, "Activity intolerance" has very specific related factors (p. 225), and I'm not seeing "cellulitis of R foot and septic shock" there.

You don't get to choose the words for the r/t in a nursing diagnostic statement. I thought we went over this before? Why make it more difficult? It's right there for you.

In this case (because I'm feeling magnanimous) I will give you the (only) five related factors for this:

* bed rest

* generalized weakness

* imbalance between oxygen supply and demand

* immobility

* sedentary lifestyle

Likewise, "Impaired skin integrity" (page 399) has a number of external and internal related factors. However, none of them is "cellulitis secondary to poor DM management."

Finally, "Ineffective health management" (page 147) and "Ineffective health maintenance" (page 146) both have very specific related factors, many of which would appear to apply to your patient, given what you've told us about her already.

Get the book. Stop making this so hard, it isn't really. Once you get your nursing diagnoses right, you'll find a great deal easier to prioritize them. At very least, you will be able to find supportive documentation for your own choice of priorities.

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

Yesss I keep doing that =/

I have the book but its one edition behind. I deff need to get the new book. I gotta stop making this too complicated. I'm looking at the r/f now for the other dx on my list. thank you as always =]

In the NANDA-I 2015-2017, "Activity intolerance" has very specific related factors (p. 225), and I'm not seeing "cellulitis of R foot and septic shock" there.

You don't get to choose the words for the r/t in a nursing diagnostic statement. I thought we went over this before? Why make it more difficult? It's right there for you.

In this case (because I'm feeling magnanimous) I will give you the (only) five related factors for this:

* bed rest

* generalized weakness

* imbalance between oxygen supply and demand

* immobility

* sedentary lifestyle

Likewise, "Impaired skin integrity" (page 399) has a number of external and internal related factors. However, none of them is "cellulitis secondary to poor DM management."

Finally, "Ineffective health management" (page 147) and "Ineffective health maintenance" (page 146) both have very specific related factors, many of which would appear to apply to your patient, given what you've told us about her already.

Get the book. Stop making this so hard, it isn't really. Once you get your nursing diagnoses right, you'll find a great deal easier to prioritize them. At very least, you will be able to find supportive documentation for your own choice of priorities.

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Get the current book. You will not be sorry. It's an improvement over the one you have, and why not use the best?

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

True that! And I would have an easier time with the dx. Cause the edition I have doesn't really list the r/t factors for every dx, less than half honestly.

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True that! And I would have an easier time with the dx. Cause the edition I have doesn't really list the r/t factors for every dx, less than half honestly.

Have never seen a NANDA-I that lacks r/t, defining characteristics, or risk factors for all diagnoses.

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

I have defining characteristics but no risk

factors for over half of them. I know the defining characteristics are like what define the dx and what your pt needs to exhibit but there's barley any r/f :/ I have the 9th edition or something like that. I don't really like my book so ima get a new one

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