Care Plan - PAD, Ineffective Tissue Perfusion?

StudentOfHealing · Nov 12, 2013

There are tons of interventions such as establishing a baseline, footcare, positioning, pain management, teaching, and collaborative management (pharmacologic approach).

Tip I learned from a professor:

As far as not feeling pulses, what else can you do? If you document "my patient has no peripheral pulse" - that won't look too good unless you do something. Right?

You used a doppler radar ... so maybe also document the

cap refill @ the nail and the actual leg/foot?

Look in your medsurg/care plan book for more interventions. On my way to bed- promise there's tons. (:

Good luck.

hopeful2015 · Nov 12, 2013

This is my first semester so we haven't officially cracked open the med/surg books but I assure you the seal is now going to be broken. Off I go to search for interventions. Thanks for the advice.

Esme12, ASN, BSN, RN · Nov 12, 2013

Lab values indicate mildly anemic
Pt warm extremities, cap refill less 3 sec
Soreness L arm at catheter insertion site for thrombolysis of R femoral occlusion b/w 2 previously placed stents.
HX: CAD, Hypertension, hyperlipidema, diabetes mellitus, previous insertion of stents coronary artery and both femoral
VS all normal range
BLE pulses barely able to palpate, doppler used for auscultation at each site
patient ad lib with 1 person assist but in actuality was fully independent
pt report 0 pain
no plans to discharge until INR reached 2.0-2.5, currently at 1.05 4 days post-op
meds include: heparin IV 1100 units/hr, warfarin 7.25mg, amlodipine 10mg, clopidogrel 75mg
Here is what I have but it doesn't fee right.
Ineffective tissue perfusion r/t obstructed blood flow in peripheral arteries aeb pulses that are not palpable in lower extremities, patient history of intermittent claudication, decreased sensation perception in patients feet.
Anyone have any advice? If this dx works I'm not sure were to go for my outcomes and interventions.

You are falling into the same trick bag that all students fall into.....picking you diagnosis and trying to fit the patient into it......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.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Is this a real patient? what care plan book do you use. Tell me about your patient.......What do they need? What do they c/o? What is your assessment? What is your patient saying? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

hopeful2015 · Nov 13, 2013

This was my pt last week. I turned my assignment in earlier today. I use the Sparks & Taylors ND & Reference Manual 9th edition. The patient was extremely independent and her major complaint was that her arm was sore due to the procedure in which they ran a catheter up her arm and down to her femoral artery to clear an occlusion b/w two existing stents. She worried about getting home to take care of her elderly mother (pt was 61 and her mother was in 80's or 90's I don't recall). She was disappointed that her release was not scheduled for at least 2 more days due to trying to get her INR level from 1.05 up to 2.0-2.5 range.

Esme12, ASN, BSN, RN · Nov 13, 2013

What does b/w mean?

Do you still need interventions? what about care giver role strain? Are her blood glucose under control? was she on any meds to control glucose?

JustBeachyNurse, LPN · Nov 13, 2013

B/w is not an acceptable abbreviation. Be careful when using abbreviations in assignments

Esme12, ASN, BSN, RN · Nov 13, 2013

Ok but what does it stand for?

JustBeachyNurse, LPN · Nov 13, 2013

I have no idea. By way? Be wary? Because with? Both within ? Backwash ? Blood work? Black/white?

Here's a list of medical /scientific uses of b/w: http://www.acronymfinder.com/Science-and-Medicine/B%2fW.html

Your guess is as good as mine. Most fundamentals books contain a list of acceptable abbreviations and often what not to use & why (such as cc and U). B/W is not even listed in my book.

StudentOfHealing · Nov 13, 2013

I think it means "Between" @ Esme12

Esme12, ASN, BSN, RN · Nov 13, 2013

Ah....said the blind man to his deaf wife.

Proof in fact for using only approved abbreviations.

Thank you!

hopeful2015 · Nov 13, 2013

b/w means between - that was my own shorthand from my notes on assessment, not in clinical write-up thank goodness. I had no idea it could mean so many other things.