First Quarter Nursing Student - Care Plan Help PLEASE!!

[jmassey01]

I have been reading a lot of the posts on this website related to care plans and notice (from what I've read so far) that the Nursing Diagnosis is not being r/t the medical Dx. This is what I am being told to do. I just turned in my first 2 and even though I passed, I have no idea what I'm doing!

I am doing clinicals at a nursing home and need some advice on what I can do to get the information I need for my care plan with the limited amount of time I have with my patient. My patient is Dx with Alzheimer's Dementia, Hyperlipidemia, Osteoporosis, Osteoarthritis, Depression, Exacerbation of COPD. Within the last year she has had 4 CBCs with decreased RBC, HGB, and HCT; 1 Basic Metabolic with decreased Potassium and increased Glucose; 2 CMPs with decreased GPT/ALT, Albumin, and increased Globulin; 1 Urinalysis with Protein 30. No other abnormal labs. Her medications are for her Alzheimer's Dementia, OA, and OP. Also on vitamin supplement and Acetaminephen for increased temp/pain.

On my Physical Assessment of her, I found no issues until I took her socks off. Her legs literally went from a normal color to completely purple with thickened, hardened, and yellowed toe nails. It was impossible to check cap refill time b/c of the color and her pedal pulses were almost non existant. I did not feel any Edema even though my instructor did (small). I'm not sure I'd know if I felt it though, unless it was very obvious, so it is possible I missed it. Her T P R were within normal range, but her B/P was 152/86.

When I toileted/bathed her, I noticed that from below her pubic symphysis all the way back to the bottom of her sacral area, was a reddened area about 2-3 inches wide. Apparently due to being left to sit in her urine and feces for extended periods of time.

She is 5'5 and 173.8lbs; 20 of which she has gained in the 1 1/2 years she has been in the nursing home.

My instructor recommended Ineffective Tissue Perfusion R/T COPD. I also think I have enough evidence for Risk for Impaired Skin Integrity R/T Alzheimer's Dementia and Depression. Any advise on which direction I should take would be greatly appreciated. My instructor has very little time for one-on-one time due to class size, so, please help!!

[Daytonite, BSN, RN]

nursing diagnoses are actually nursing problems. the "related to" parts of the diagnostic statements are actually given to us in the nanda diagnostic taxonomy (a listing and classification of all the nursing diagnoses). so, if you have a nursing diagnosis reference you can look up the related factors for any of the nursing diagnoses you use. for many of the physiologically based nursing diagnoses the related factors are based upon knowing the pathophysiology of the person's medical disease. i have information on how to write a care plan on this thread in the general nursing student discussion forum: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. care planning follows the steps of the nursing process. you can, if you want, buy a copy of the book, nursing care planning made incredibly easy, to help you. however, when i help students with care plans i pretty much follow the same advice given in this book.

step 1 assessment - assessment consists of doing the following:

• a health history (review of systems)
  
• performing a physical exam - for care planning we are interested in what is abnormal about the assessment. a care plan is a listing of the patient's nursing problems. an assessment is how we search and find evidence that prove these problems [nursing diagnoses] exist.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - for care planning we are interested in what the patient cannot do for themselves and what they specifically need help with
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - your patient has the following medical diseases that you should look up the pathophysiology, signs and symptoms and complications of: alzheimer's dementia, hyperlipidemia, osteoporosis, osteoarthritis, depression, and copd [chronic obstructive pulmonary disease] which is a group of diseases that includes 1) chronic obstructive bronchitis 2) chronic obstructive asthma 3) emphysema 4) chronic bronchitis with emphysema. you should be checking to see if during your reading you remember any signs and symptoms in your patient that you realize that you missed. you write them down right away. this is how you learn about the disease and what you may have missed seeing in your patient on the day(s) you assessed them.
  
• reviewing the signs, symptoms and side effects of the medications they are taking - look up the signs, symptoms and side effects of the drugs your patient is taking in a nursing drug reference. if, during your reading, you remember any signs and symptoms that your patient might have had, write them down right away.
  

a person with alzheimer's dementia could have some of these behaviors: disorientation to person, place or time; poor judgment; agitation; sleeplessness; paranoid ideation; gradual dependence on others for help in accomplishing adls; and as alzheimer's reaches its late stages they become physically immobile. someone with one of the diseases of copd would probably have some respiratory symptoms: a cough or shortness of breath with activity.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - just as our legal system won't charge anyone with a crime without evidence, we don't diagnose a patient with a nursing problem unless we have evidence to back up our claim as well. here is the evidence you presented that i can use for care planning:

• legs completely purple with thickened, hardened, and yellowed toe nails
  
• pedal pulses were almost non existent
  
• edema
  
• b/p was 152/86
  
• reddened area about 2-3 inches wide from pubic symphysis all the way back to the bottom of her sacral area due to being left to sit in her urine and feces for extended periods of time
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - using a nursing diagnosis reference i can match that evidence above to these nursing diagnoses and form these nursing diagnostic statements:

• impaired tissue perfusion, peripheral r/t impaired transport of oxygen aeb pedal pulses were almost non existent, legs completely purple and edematous.
  
• impaired skin integrity r/t moisture, humidity and impaired circulation aeb a reddened area about 2-3 inches wide from pubic symphysis all the way back to the bottom of her sacral area and thickened, hardened, yellowed toe nails on feet
  

i have no doubt that with more evidence there could be more diagnoses.

risk for impaired skin integrity r/t alzheimer's dementia and depression

the reason this diagnosis would not be appropriate to use is because

• impaired skin is not an
  anticipated
  problem here, it is an
  actual
  problem that already exists and there is evidence of it
  
  
• the "r/t" part of the diagnostic statement must be what is causing the problem (nursing diagnosis). how is alzheimer's dementia or depression causing this patient to have skin breakdown--realistically? does that even make any kind of rational sense? when you read the statement that i gave above (
  impaired skin integrity r/t moisture, humidity and impaired circulation aeb a reddened area about 2-3 inches wide from pubic symphysis all the way back to the bottom of her sacral area and thickened, hardened, yellowed toe nails on feet
  ) you know that the red area in her butt crack is a combination of moisture and humidity and those nasty toenails of hers are a result of a circulation problem.
  
  
• there are only certain instances when alzheimer's dementia and depression can be used as a related factor or risk factor for specific diagnoses. this is not one of them. in general, medical diseases cannot be used as related factors or risk factors in nursing diagnostic statements. they need to be converted to what is called
  nursing language
  which is simply a more acceptable generic medical terminology. for instance, instead of "arthritis", a medical disease, we will put "inflammation of joints" in our nursing diagnostic statements.
  
  

ineffective tissue perfusion r/t copd

your instructor really recommended this diagnosis? it is wrong for several reasons. (1) the body system that the

ineffective tissue perfusion

is affecting must be specified. (2) this diagnosis is always regarding how oxygen is failing to get to those tissues so placing any kind of medical disease as the etiology isn't explaining that. (3) patients with copd who have tissue perfusion problems in their lung tissues are specifically having pulmonary edema or pulmonary embolism problems otherwise they have

impaired gas exchange r/t alveolar-capillary membrane changes secondary to copd

. i would have expected to hear that this patient has shortness of breath, coughing and chest pain. they would be having hypoxia and quite possibly turning blue because

they can't get enough oxygen

. you can see nursing diagnosis pages for these two here:

• ineffective tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral
  
  
• impaired gas exchange