Diabetic foot ulcer

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Hi there guys! I am new here! I am a 2nd semester student and today I had a very complicated patient and to top it all of, I lost most of my patient's information (eek). So I am trying to do my best on my care plan from what I remember and the notes I was able to salvage. I am hoping for a little bit of advice or confirmation that I am on the right track with my care plan, I greatly appreciate it. This is my patient's information:

65 yo Hispanic male, hx chronic left diabetic foot ulcers, DM 2, dyslipidemia, HTN, CHF with EF 25-35% (N >55%, echo done 2/14/14), hx MI, peripheral neuropathy, CKD, aortic atherosclerosis. Pt has been non compliant with post-op shoe, and blood sugar monitoring. Left foot ulcers were debrided 5/28/14, given Keflex, debridements on 6/20/14, 7/10/14, 7/31/14. Pt developed blisters on top of left foot and saw podiatrist again on 9/24/14, debrided again and gave rocephin x1 and Keflex. patient returned on 9/29 for CC worsening symptoms, signs of infection; drainage, odor, cellulitis of ankle and leg. Sent to ED for admission and IV antibiotics, XR did not reveal osteomyelitis. I&D on 9/30/14. 10/2 angiogram s/p angioplasty by vascular, 10/3 debridement of left foot, 10/4 no changes, plan for wound vac, 10/8 wound vac placement, BP lightly low, sbp 80s, repeat upon laying down sbp 100's, held ace, bb, laxis for today. May consider amputation if not healing

10/9 2 central toes gangrenous, wound not improving.

Current meds: insulin regular human, vanco, clopidogrel, atorvastatin, insulin nph human, tamsulosin, sodium cl, docusate, heparin

VS

10/8/14

BP 127/72

HR 90

T 98.6

RR 20

O2 RA 97%

10/9/14 0752

BP 122/73

89

99.3

RR 16

o2 RA 95%

PAIN 3

10/9/14 1126

95/61, HR 74, TEMP 97.5, RR 16, O2 RA 99%

10/9/14 1600

98/58, HR 75, PAIN 2, TEMP 98, RR 18, 02 100%

wound culture was - for staph and enterococcus

HGBA1C 8.4 on 7/7/14

his BNP was extremely high but because I lost my patient's info, I don't know the exact number

his left foot is bandaged. right foot pedal pulse diminished, popliteal pulse felt, skin warm, caprefill

his recent labs:

10/9/14

WBC 10.8, HGB 9, HCT 25.8, PLT 341, NA 131, K 5.4 , then retaken and at 4.7, CL 102, BUN 24, CREAT 1.29, GFR 56

So my nandas that I am thinking of so far are

impaired tissue perfusion (peripheral)

decreased cardiac output

infection

fluid vol overload

impaired nutrition, more than body requirements

am I going in the right direction? I also get stuck on my inferences and the R/T part...

Any help would be GREATLY appreciated!!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Welcome!

You are on the right track....before I add more....what NANDA resource are you using?

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Mosby's 4th Edition

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I'm getting a little lost b/c my patient has that poor ejection fraction (left ventricular systolic dysfunction) , dm2, and aortic atheroscerlosis. So on the "Ineffective tissue perfusion (peripheral) r/t__________________" is where I get suck. Is it related to the left ventricular systolic dysfunction and atherosclerosis? So would I write it "Ineffective tissue perfusion (peripheral) r/t decreased hgb concentration in blood 2nd to dm2 AEB......". This is where I get a little mixed up.

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Or what about this nanda " ineffective tissue perfusion (peripheral) r/t impaired arterial circulation AEB diminished RLE pedal pulse, thickened and discolored pedal nails, and decrease in HGB". How's that for nanda #1? Lol

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

OK....let me look here

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
65 yo Hispanic male, hx chronic left diabetic foot ulcers, DM 2, dyslipidemia, HTN, CHF with EF 25-35% (N >55%, echo done 2/14/14), hx MI, peripheral neuropathy, CKD, aortic atherosclerosis. Pt has been non compliant with post-op shoe, and blood sugar monitoring. BP lightly low, sbp 80s, repeat upon laying down sbp 100's, held ace, bb, laxis for today. May consider amputation if not healing

10/9 2 central toes gangrenous, wound not improving.

Current meds: insulin regular human, vanco, clopidogrel, atorvastatin, insulin nph human, tamsulosin, sodium cl, docusate, heparin

HGBA1C 8.4 on 7/7/14

his BNP was extremely high but because I lost my patient's info, I don't know the exact number

his left foot is bandaged. right foot pedal pulse diminished, popliteal pulse felt, skin warm, caprefill

10/9/14 1126

95/61, HR 74, TEMP 97.5, RR 16, O2 RA 99%

10/9/14 1600

98/58, HR 75, PAIN 2, TEMP 98, RR 18, 02 100%

his recent labs:

10/9/14

WBC 10.8, HGB 9, HCT 25.8, PLT 341, NA 131, K 5.4 , then retaken and at 4.7, CL 102, BUN 24, CREAT 1.29, GFR 56

Ok...you make your diagnosis based on what the patient NEEDS and on your ASSESSMENT.....you prioritize according to what can kill the patient first...ABC's. Then you take into consideration Maslows.
decreased cardiac output

infection

fluid vol overload

impaired nutrition, more than body requirements

Here is what I see...

Decreased Cardiac Output

Excess Fluid Volume

Deficient Fluid Volume

Ineffective Health Maintenance

Impaired Skin Integrity

Impaired Tissue Integrity

Ineffective peripheral Tissue Perfusion

Risk for unstable blood Glucose level

Deficient Knowledge (specify)

Risk for Bleeding

Risk for Electrolyte Imbalance

Care plans are al about the patient assessment. What the patient needs, what the patient says, what the symptoms are....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.

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.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

So looking at this patient...I am MOST concerned about the patient B/P, His elevated BNP, his poor renal status, the risk of electrolyte imbalances due to his poor renal status and diuretic usage. Did you call the MD when you held the B/P meds and lasix? A patient with a poor ejection fraction might still need the ACE inhibitor to decrease afterload (to he;p the heart work less hard) so the heart can effectively pump off fluid or they can go in to failure.

I am also concerned about sepsis.

You mention infection....impaired nutrition, more than body requirements. NANDA does not have infection as a nursing diagnosis...it si risk of infection....that doesn't apply here because he clearly has an infection. IN your assessment provided you did not mention the patient's weight you will need to be sure you document the patients weight.

So looking at these...

Decreased Cardiac Output: R/T poor EF pump failure

Excess Fluid Volume: R/T pump failure elevated BNP

Deficient Fluid Volume: might be present the patient might be wet in his lungs with low circulating volume AEB low B/P and low H/H

Ineffective Health Maintenance : non adherence to medical regimen

Impaired Skin Integrity: wound

Impaired Tissue Integrity: wound

Ineffective peripheral Tissue Perfusion: gangrene

Risk for unstable blood Glucose level: A1C

Deficient Knowledge (specify):

Risk for Bleeding: heparin

Risk for Electrolyte Imbalance: renal insuff, abnormal labs diuretic, use low GFR

Each NANDA diagnosis has a definition, defining characteristics, and related to content. Your patient must fit within these diagnosis parameters in order to use the diagnosis. For example

NANDA defines...Decreased cardiac output: Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body

Defining Characteristics AT LEAST one of the following

Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings: :

Altered Contractility: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional: Anxiety; restlessness

Related Factors (r/t): Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

Ackley: Nursing Diagnosis Handbook, 10th Edition

So where does your patient fit? You know his EF is low do you KNOW it is AT LEAST related to altered contractility AEB decreased ejection fraction of 25-35%

Your nursing diagnosis statement should be thought about like this....GrnTea says it best.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

"Related to" means "caused by," not something else

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Yes, thank you. Sorry I didn't respond faster. It's 1 pm here and my care plan is due at 3pm and I'm stressed out trying to work up my care plan.

These are my nandas so far:

[TABLE]

[TR]

[TD]1. decreased cardiac output r/t altered contractility AEB ↓ EF 25-35%, high BNP, diminished pedal pulses, and fatigue during ambulation 2˚ left ventricular systolic dysfunction

[/TD]

[/TR]

[TR]

[TD]2.ineffective tissue perfusion(peripheral) r/t impaired arterial circulation AEB diminished pedal pulses, thickened discolored pedal nails, and decrease in H&H

[/TD]

[/TR]

[/TABLE]

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[TABLE=class: MsoNormalTable]

[TR]

[TD]1. decreased cardiac output r/t altered contractility AEB ↓ EF 25-35%, high BNP, diminished pedal pulses, and fatigue during ambulation 2˚ left ventricular systolic dysfunction

[/TD]

[/TR]

[TR]

[TD=width: 516, bgcolor: transparent]2.excessive fluid volume r/t pump failure aeb increased BNP

[/TD]

[/TR]

[TR]

[TD=width: 516, bgcolor: transparent]3.ineffective tissue perfusion(peripheral) r/t impaired arterial circulation AEB diminished pedal pulses, thickened discolored pedal nails, and decrease in H&H

[/TD]

[/TR]

[/TABLE]

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
[TABLE=class: MsoNormalTable]

[TR]

[TD]1. decreased cardiac output r/t altered contractility AEB ↓ EF 25-35%, high BNP, diminished pedal pulses, and fatigue during ambulation 2˚ left ventricular systolic dysfunction[/TD]

[/TR]

[TR]

[TD]2.excessive fluid volume r/t pump failure aeb increased BNP [/TD]

[/TR]

[TR]

[TD]3.ineffective tissue perfusion(peripheral) r/t impaired arterial circulation AEB diminished pedal pulses, thickened discolored pedal nails, and decrease in H&H[/TD]

[/TR]

[/TABLE]

1) decreased cardiac output has these specific characteristics. I don't see diminished pulses amongst them

Defining Characteristics AT LEAST one of the following

Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings: :

Altered Contractility: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional: Anxiety; restlessness

Which of these symptoms does your patient have? THAT is your as evidenced by related to.

1) decreased cardiac output related to decreased cardiac output as evidenced by (related to) EF, BNP, labile B/P (BP 127/72and 95/61) and fatigue.

do you see how that tied in?

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