Care Plan Help/Necrotic Ulcer

  1. Guys, I need your help. I have a careplan to do on a patient with chronic renal failure who developed an ulcer on his fistula. I am lost. Care plan due Tuesday,please help!!!!!
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    About GAA30

    Joined: Jan '06; Posts: 49; Likes: 6


  3. by   srg4784
    how about.......impaired skin integrity r/t renal failure AMB presence of decubitus ulcer on *insert which, L or R* fistula......... also remember, with renal failure makes it more prone to more susceptible to infections so you can even do a risk for infection also, if your doing more than one care plan. Sorry I can't be of more help but I don't have any textbooks or anything with me at the moment.

    I'm not going to do all your interventions for you but I can tell you that eating protein is important...protein is needed for healing..... also prevention of further breakdown and prevention of infection are key interventions......just to give you some ideas. With all my patients that had skin breakdown I always made it a point to have them select food from their menu that were high in protein, so that might be an intervention that you could do!

    Also don't forget FLUIDS FLUIDS FLUIDS, in regards to fluid overload, CRF kidneys are overloaded and with this comes weight gain and decreased urination!!!
    Last edit by srg4784 on Jan 15, '07
  4. by   Daytonite
    let me help you get on the right track. the steps of the care planning process are as follows:
    1. assessment
    2. nursing diagnosis
    3. planning
    4. implementation
    5. evaluation
    each step leads you to the next. part of the reason you are lost and the reason why i can't give you much specific help is because you haven't given any of the patient's symptoms. you cannot begin choosing nursing diagnoses or nursing interventions until you take a good look at all the assessment data that you collected on this patient. you need to sit down and go through all the information you got from the patient's chart and from your physical assessment. to determine nursing diagnoses, you must first create a list of the patient's abnormal findings. these can come from any of your data sources. these abnormal findings become the defining characteristics that will determine which nursing diagnoses you will use. this is, by far, the hardest part of doing your care plan. i say that because once you have determined your defining characteristics and nursing diagnoses, the rest of the care plan will fall into place. you see, the nursing interventions are based on those abnormal findings. those are the things you ultimately end up, as a nurse, treating the patient for.

    so, what were the patient's symptoms of renal failure? fluid retention? all kinds of electrolyte imbalances? is there any urine production at all? any azotemia present? numbness or tingling in the extremities? hypertension? nausea? fatigue? any anemia? what about any skin discoloration or itching? this is very common in crf. how has the crf and having hemodialysis affected the patient's lifestyle? is the patient employed? does the patient have any underlying disease such as diabetes? what was your assessment of the ulceration on the fistula? any redness, swelling, draining, pain? any fever? were blood cultures taken? is the fistula still being used or was a central access catheter placed? these are just some of the questions i would want answered before even tackling the actual writing of the care plan.

    some nursing diagnoses that can possibly be used with this chronic renal failure patient with a complication of the dialysis fistula might be:
    • excess fluid volume
    • impaired urinary elimination
    • fatigue
    • nausea
    • disturbed body image
    • impaired comfort
    • ineffective protection
    • risk for infection
    you might find it helpful to review some of the posts in these threads on writing care plans:
  5. by   nurse4theplanet
    Quote from srg4784
    Also dont forget .....FLUIDS FLUIDS FLUIDS....okay I'm really going to stop now b/c my food is getting cold, I absolutely love care plans though and I can't help myself.
    Must be careful with fluids. Pt is in renal failure remember.
  6. by   Daytonite
    CRF patients are overloaded with fluids because they often have lost the ability to produce urine. It is not unheard of for CRF patients to have 5 pound fluid gains over 2 day periods. Most of these patients are on fluid restrictions for this reason. One of the nursing actions taken before and after hemodialysis is a body weight to get an accurate measurement of how much fluid was taken off the patient during hemodialysis. Therefore, a nursing diagnosis of Excess Fluid Volume R/T sodium retention AEB weight gain over a short period of time or anasarca is totally appropriate.
  7. by   srg4784
    Quote from asoldierswife05
    Must be careful with fluids. Pt is in renal failure remember.

    Yeah, that's what I meant...sorry that I didn't explain it better, I was really enjoying that food. I had a pt. this semester that was CRF, she gained so much weight, she was also CHF and she was on fluid restriction but no one was following it, didn't even have a hat in the one was charting all of her intake.....also she was on a REGULAR DIET..... thankfully the nurse that dad took care of all that and my teacher was outraged with experience that helped me out alot b/c from now on when I have a pt. w/CHF or CRF...that will be in my head FLUID RESTRICTIONS.......and w/CHF cardiac diet........make sure all necessary precautions....hat in toilet!!!
  8. by   Mattmcg56
    looking for goals and interventios on skin integrety on a patient who has come out of hdu
  9. by   Mattmcg56
    hi guys got exam on friday and the question is identify one important nursing problem from the senario and set three clear goals related to this problem.
    i choose potential impaired skin integrety
    the senario is patient has come from H.D.U. after cabg operation.
    the other part of the question is interventions i would carry out to enable goals for skin integrety please help
  10. by   Daytonite
    Hi, Mattmcg56! H.D.U. . .does this stand for Hemodialysis Unit? Or, Heart Disease Unit? Is the impaired skin the incision for the CABG or for the incision of the vein donor site? What is going on with the wound? Infection? Drainage? Fever? What's the problem here?

    Welcome to allnurses!
  11. by   Mattmcg56
    H.D.U. stands for high Dependency unit, the impaired skin is on all site wounds e.g. cantral line, cannula site,pacing wires,and cheast drain site
  12. by   Daytonite
    Mattmcg56. . .let me get this right. In this scenario you have a patient that has come from a high dependency unit. So, can we assume that he went through DTs because he was detoxing from some drug or alcohol? Also, he has had a CABG.

    These are his only two major problems? Was there any mention of any other underlying heart disease? Were any medications mentioned? Were any specific medical diseases mentioned at all?
  13. by   Mattmcg56
    the patient had a corony heart bypass surgery and he has just came out of H.D.U
  14. by   Daytonite
    a post op patient in general may or may not have some of the following problems:
    • surgical pain
    • breathing problems
    • thrombophlebitis of the lower extremities
    • elevated or depressed temperatures
    • problems with the incision(s) (dehiscence, evisceration, infection)
    cabg patients, in particular may have
    • arrhythmias
    • swelling or aching of the leg(s) where the donor vessel was taken as well as decreased sensations or numbness in those limbs
    • pain over the sternum
    here is information on cabg:
    i'm a little confused here. are you being told that the patient has some kind of problems with the central line, cannula site, pacing wires and chest drain site? if not, i wouldn't assume these things. what i tell other nursing students is to take medical information you are given, list the normal symptoms the doctor would expect to find and extrapolate nursing interventions from those symptoms because nurses can also treat the symptoms--not the medical disease.

    my suggestions would be to work with the following problems for this imaginary patient (unless you've got other information you've been given that you haven't told me about):
    • surgical pain
    • presence of an incision over the sternum
    • has just gone through detox of some substance
    for these i would use the following nursing diagnoses:
    1. impaired skin integrity
    2. acute pain
    3. acute confusion (this would be due to withdrawal) or you could also use disturbed sensory perception if the patient is going to be hallucinating
    for impaired skin integrity two goals that you could use are:
    1. in one month the midsternal incision will be completely healed.
    2. by the day of discharge from the hospital the patient will demonstrate the proper way to cleanse and redress his/her midsternal incision
    i can't think of a third one at this moment, but this is your assignment.

    hope that helps you out.