Help w/ Nursing Diagnosis?

[luvnhim]

I have to complete a concept map for my patient and was wondering if someone will let me know if I'm writing my nursing diagnosis right.. any help would be greatly appreciated. :)

My patient has had below the knee amputation on her left leg due to Diabetes and is obese. She says she is unable to bear weight on her right leg. I tried to see if she could & she said she wasn't able to but the CNA's said she would do it for her daughters every now and then. A lift is used in order to transfer the patient to her shower chair or the chair she likes to sit in during the day. She also has limited ROM.

Nursing Diagnosis:

Impaired physical mobility related to left below the knee amputation secondary to Diabetes Mellitus as evidenced by limited range of motion, the inability to bear weight on her right leg, and the inability to move in her environment, including bed mobility and transfers.

Does this sound right?

Thanks in advance! :)

[sleepysilver]

For starters, a nursing diagnosis cannot include any medical diagnoses so you can't say Diabetes Mellitus in your diagnosis, you would have to use something like "elevated blood sugar" or whatever it is that is specific to your patient.

[NCRNMDM, ASN, RN]

I think it sounds fine. We are told that we can include a medical diagnosis as long as we say secondary to, like you did. I feel that it is incorrect to say that a nursing diagnosis cannot include a medical diagnosis. You can't diagnose someone with pneumonia, but you can diagnose them with ineffective breathing pattern or impaired gas exchange secondary to pneumonia. There isn't anything wrong with using a medical diagnosis to back up the nursing diagnosis you have made.

[nurseygurlie]

I think your diagnosis sounds fine, but if you want to dig deeper it sounds like the issue is not the amputation but the weakness in the right leg. It's good practice to use your documentation to paint a picture. Always mention the affected side if you are talking about an amputation, mastectomy, etc.

A diagnosis of impaired physical mobility is difficult because you should only use it if you can have some kind of affect on the problem. If the problem is related to the amputation, then your interventions should be geared towards facilitating movement in spite of the amputation (working with a prosthetic, obtaining an assistance device, etc). I guess this is just nitpicky, but if it were my careplan I would include the weakness in the right leg, because that is where the problem is and that is where your interventions will be. Also, when the diagnosis is related to a subjective problem, like pain, weakness, or numbness, I like to include a quote from the patient explaining it. That's just personal preference but the instructors seem to like it.

Impaired physical mobility r/t left leg below-the-knee amputation and right leg weakness secondary to DMII AMB inability to bear weight on the right leg, limited range of motion, and "My right leg is too weak to stand on."

Hope that helps you expand on your ideas!

[nurseygurlie]

For starters, a nursing diagnosis cannot include any medical diagnoses so you can't say Diabetes Mellitus in your diagnosis, you would have to use something like "elevated blood sugar" or whatever it is that is specific to your patient.

This is correct for the "related to", which is why if you want to include the diagnosis the problem is connected with, you can use "secondary to".

The related to is necessary, the secondary to is optional.

[nurseprnRN, BSN, RN]

didn't you just post this same patient on another thread?

it is perfectly acceptable to say she had her bka d/t diabetic peripheral vascular disease. that's a act. the nursing diagnosis is not the diabetes, it's there is that she has limited mobility related to (because she has) an amputation. i think you might also want to list some other reasons she has limited mobility.

as another poster clearly explains, you want to be assessing (looking for) causes for her lack of mobility that relate to her just having one remaining leg-- might not be strong enough to support her, she might be deconditioned and weak, she might have heart disease and be short of breath, she might be fearful of falling, she might very well have diabetic neuropathy so she can't feel the floor well, balance might not be good, vision might not be good, she might be refusing pt for a number of reasons or not following their program for safe mobility; all of these would contribute to why she doesn't get around too well. nursing tries hard to see the big picture (holistic model), where medicine mostly just sees a medical diagnosis (disease model) and stops right there.