Discharge paper-HELP!

bellagrace903 · Mar 19, 2009

btw- medical Dx is bilateral cellulitis

Daytonite, BSN, RN · Mar 19, 2009

it is unfortunate that i didn't see your post until today. i look at posts in this forum after i address posts in the nursing student assistance forum first. i can still offer you some advice.

i have no idea what a "discharge paper" is. many instructors and programs name their assignments different things. i wasn't clear as to what you were to do with all this data you posted. i don't know what "mono k/ul, 0.9 h" means either, but i can tell you how i would have found information about it. i would have noted which lab form it was reported on (chemistry, blood profile, etc.) and i would have called the lab and asked them to explain it to me. you can do that. and, you can make the call from your house. just tell them you are a student looking at a patient's labwork and you have a question about a lab result you are looking at--could they please tell you what this lab test is because you can't find information about it anywhere. don't tell them you are calling from home. they should tell you. if they can't, ask if there is someone there who can tell you.

regarding your nursing diagnoses and interventions with rationales. . .(1) they are sequenced in the wrong order of priority. i resequenced them per maslow's hierarchy of needs. (2) there are problems with their construction and they are detailed individually below. (3) none of them contained rationales for the nursing interventions if you had listed interventions. rationales are the reasons why you are doing each of them.

a nursing diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem and resulting in the symptoms. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this. etiologies, if they are other than of a medical source, are often the focus of outcomes and long term goals.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they could be signs and symptoms of the medical disease the patient has, their responses to their disease, problems accomplishing their adls. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals. anticipated problems (diagnoses that begin with the words "risk for") do not have symptoms because they do not yet exist.

impaired respiratory function r/t immobility aeb diminished breath sounds

per nanda this is not an official diagnosis. if this is one your instructors want you to use make sure you are referring to correct related factors and symptoms. however, what i know about the corresponding nanda respiratory diagnoses is that "immobility" is not a related factor with them.
the nanda diagnosis for this, based on the information you have provided about this patient, would be ineffective breathing pattern r/t obesity aeb diminished breath sounds
respiratory diagnoses have to do with what, specifically, is going on in the lungs or respiratory track. your related factor is why that has occurred.
you have listed no nursing interventions for the diminished breath sounds or rationales for them.

ineffective tissue perfusion r/t impaired circulation aeb lower extremities warm, tender to touch and +1 edema.

palpate the dorsalis pedis pulses in both feet, use a doppler if indicated. - this really doesn't relate to any of the aeb items. there is nothing in the historical data to indicate that she has a circulation problem. i would still do it, but it would not be a priority intervention.
elevate the legs above the heart level. be sure not to apply pressure to the open wounds. - address the wounds in the diagnosis of impaired skin integrity.
measure the circumference of both legs and be sure to mark the site to facilitate accuracy of recordings.
monitor and record daily weights and intake and output. - why? this would be if you were monitoring for a fluid deficit or excess.
how about doing at least daily circulation and neuro checks of these legs?
how about doing some things to get these legs moving? some rom?
what would you like to teach this patient about her legs?

ineffective peripheral tissue perfusion r/t --ok, i got stuck here!--

circulatory care: arterial insufficiency

circulatory precautions

i put these two ineffective tissue perfusion diagnoses together because nanda up until 2008 kept the tissue perfusion diagnoses together. in 2008 they split ineffective peripheral tissue perfusion into its own diagnosis. it would be appropriate to use it for a patient who has cellulitis of the lower extremities. you can also use the older way of formulating the diagnosis of ineffective tissue perfusion, peripheral if you like. it's just that with the new diagnosis, nanda gave specific guidelines on related factors and defining characteristics (symptoms) that go with it that made it more clearer than before. i don't understand why you saw the need to add a second ineffective peripheral tissue perfusion diagnosis unless there was another body area that was having symptoms of perfusion problems. other than the intermittent confusion which could questionably be a cerebral perfusion problem, her legs (peripheral area) are the only problem area that needs to be addressed.
i would disagree that the related factor here is "impaired circulation". we don't know that. the only medical diagnoses are cellulitis and a history of schizophrenia. there is nothing there about any heart or circulation disease. was she getting any heart medication that might be a clue of any heart or circulation disease? if not, then the only thing i can see in her abnormal data that contributes to her tissue perfusion problem is her inactivity (which probably aggravates poor circulation) and lower leg edema.
"extremities warm" is a normal finding and i would not include it with aeb items
your data about the edema was that it was 1+ edema in l&r legs. that should be included in your diagnostic statement.
other evidence of this problem that needs to be included in your aeb items is the pale skin of the lower legs
was there anything unusual about her toenails other than they needed cutting?
better: ineffective tissue perfusion, peripheral r/t sedentary lifestyle and edema aeb 1+ edema and pale skin in both lower legs and pain when lower legs/feet are touched.
you have given no rationales for your nursing interventions.

activity intolerance r/t ---stuck again... i feel too redundant?!---

exercise therapy- ambulation

you have no evidence to support this diagnosis. activity intolerance (you have to read the definitions, related factors and defining characteristics of these diagnoses to understand what they are:
activity intolerance) has to do with the patient getting sob, their heart racing, b/p rising and them getting fatigued with activity. i noticed that she does have general weakness and refuses physical therapy.

impaired physical mobility r/t pain in legs aeb refusal to participate in pt session.

promote exercise -be specific for the help that the patient needs for the problem that she has

thromboembolus precautions - if this is a potential threat then diagnose

risk for injury

and put the interventions for the prevention of dvts there.

pressure ulcer precautions

- if this is a potential threat then diagnose

risk for impaired skin integrity

and put the interventions for these under that diagnosis.

you have no evidence that i could see to support using this diagnosis. "refusal to participate in pt session" is not evidence of impaired physical mobility which is limitation in independent, purposeful physical movement of the body of one or more extremities (page 124, nanda international nursing diagnoses: definitions and classifications 2009-2011). what it is, however, is ineffective health maintenance r/t unwillingness to cooperate with medical plan of care aeb refusing to work with physical therapists
her obesity is also a related factor that contributes to this problem.
evidence (aebs) for impaired physical therapy are things like walking slowly, hanging onto objects to maintain balance, having to use assistive devices, instability, uncoordination with movements. you can see these things. if you saw something wasn't quite normal and stood out from a crowd about her movements, describe it and that is her impaired physical mobility.
decreased motor strength, one of your data items, is an aeb for this diagnosis
again, you listed no rationales for your interventions.

impaired skin integrity r/t open wounds aeb warm, red, tender to touch extremities.

skin care- topical tx - which skin and where?

wound care

- as i mention below, we had patients with weeping legs. this skin needs protection. this diagnosis is usually classified as a safety need. describe how you are going to protect this skin with this wound care.

your related factor (r/t) always has to indicate why (the cause) the problem, which is the nursing diagnosis, is happening. "open wounds" do not cause impaired skin integrity. they are proof of it. why did her skin break down and open up? did you do any reading about cellulitis? its features are inflamed, macerated tissue. maceration is softening of the skin by fluid. what fluid? the edema that is present. where does this edema come from? the inflammation. the 4 cardinal signs of inflammation are redness, heat, swelling and pain. better to use: tissue inflammation
warm skin is a normal finding. this should not be listed as an aeb.
"tender to touch extremities" does not tell us anything about how this skin is impaired. it should not be listed as an aeb for this diagnosis.
your aeb items should be descriptions of what the skin of her legs looks like. i've seen lots of patients with cellulitis of the legs. they are swollen and red and often weeping pale yellow serous fluid. this page of the merck manual gives the signs and symptoms:
http://www.merck.com/mmpe/sec10/ch119/ch119b.html.
no rationales for the interventions are given.

infection r/t medical diagnosis (do i write that or put the actual diagnosis or what?!) aeb lab results (should i list the applicable ones here?) and strong, foul odor from legs

protection

- what does this mean?

unless this is an acceptable nursing diagnosis that your program allows you to use, nanda does not allow this because it is diagnosis of a medical condition. if the patient already has been diagnosed with an infection, break her infection down into the signs and symptoms that she has of it and make nursing diagnoses for those. ex: for elevated temperature use hyperthermia, for low wbc count use ineffective protection.
patients with a local infection (an infection confined to one area) are always at risk for the infection going into their bloodstream and becoming systemic. this is called sepsis. this happens when the body's own defenses are exhausted and the infection is just too overwhelming for it to fight off anymore. the diagnosis to use for this is risk for infection r/t inadequate secondary defenses. there are no aebs with a "risk for" diagnosis. interventions are:
- strategies to prevent the problem from happening in the first place
- monitoring for the specific signs and symptoms of this problem
- reporting any symptoms that do occur to the doctor or other concerned professional

acute pain r/t (infection?!) aeb pt requesting pain rx after dressing changes.

pain mgmt

- you have to be specific in a care plan

pain is from actual or potential damage to tissues of the body. that is from the nanda definition. this has already been touched on above. inflammation and maceration is what are causing the tissue damage to her legs, and thus, the pain. so, "tissue inflammation" is the related factor here.
"pt requesting pain rx after dressing changes" is evidence that she has pain, but you can do better. as a nurse you will have to do much better in recording patient's responses to pain. assessment and description of pain includes the following (you might want to copy these down):
- where the pain is located
- how long it lasts
- how often it occurs
- a description of it (sharp, dull, stabbing, aching, burning, throbbing)
  - have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
  [*]what triggers the pain
  [*]what relieves the pain
  [*]observe their physical responses
  - behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
  - sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
  - parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
[*]suggestions for nursing interventions for acute pain:
- assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
- assess and document where the pain is located and what, if anything, makes it worse or better
- observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
- give pain medication as ordered
- provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
- reposition the patient
- give a back massage
- use short, simple relaxation exercises to distract the patient's attention
- dim the lights in the room and keep noise down
- play soft, soothing music
- reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
- monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
- teach the patient about prescriptions they will be going home with including the dosage, how they should be taken and any side effects

risk for imbalanced nutrition r/t immobility and blindness aeb..... ?? (she's obese)

nutrition mgmt - interventions for potential problems is

always

to prevent the problem (risk) from occurring. problems get managed. if you feel there is a need to

manage

something here, then there is a problem and this has been diagnosed incorrectly.

i wouldn't use this. she's overweight. what is her risk? i don't see one.

risk for constipation r/t immobility aeb need for milk of magnesium

there are no aebs (evidence) for potential problems. if there are, then that changes the name of the diagnosis. milk of magnesia is a medical treatment that requires a physicians order and it is not a symptom of constipation anyway. symptoms of constipation are not having a bowel movement in __ days. if this patient is at risk for constipation it might be because she has suddenly become immobile, dehydrated, npo or maybe she was given barium contrast and while she always had a regular bm you are worried that she is going to get constipated.

risk for disuse syndrome r/t inability to ambulate aeb refusal to participate in pt session.

promote exercise with strength training - interventions for potential problems is

always

to prevent the problem (risk) from occurring.

this diagnosis is specifically used in patients with certain chronic diseases. i don't believe your patient qualifies for use of this diagnosis.

i would add. . .

disturbed sensory perception, visual r/t altered sensory reception secondary to cataracts aeb legal blindness
risk for falls r/t intermittent confusion, anemia, impaired physical mobility and blindness