Need help with care plan

i can tell you are in a muddle. let me first clarify that a care plan is about ascertaining what the person's nursing problems are (diagnosing) and then developing a strategy (plan) to do something about them. our weapon of choice for accomplishing this is the nursing process. some students, in their panic and oblivion, forget about this tool that their instructors spend a good deal of time drumming into them and head for care plan books. that is fine although not all medical problems will be covered in them. and, if anyone takes the time to read the preface and beginning chapters of those books they would discover that the writers of care plan books follow the nursing process to write the care plans in those books.

nursing diagnoses are always based upon the symptoms (abnormal data) your patient is having. medical diagnoses, as well, are always based upon the symptoms a patient is having. for nursing diagnosing, the symptoms we look for are not only the same ones the doctors focus on, but also include patients responses to their diseases and conditions as well as their ability to perform their adls. every nursing diagnosis has a list of signs and symptoms (nanda calls them defining characteristics) and before you assign any nursing diagnosis to a patient you should check to make sure that they have one or more of the symptoms listed under a nursing diagnosis. you should also double check the definition of the nursing diagnosis to make sure it is indeed the correct problem that the patient has. a list of the nanda nursing diagnoses, their definitions, defining characteristics (signs and symptoms) and related factors (causes) can be found in the appendix of taber's cyclopedic medical dictionary which most students have their own copy of.

let me show you how to care plan for this patient's nursing problems based on what you have told us about him using the nursing process to help you. the first 3 steps are the most crucial. . .

step 1 assessment - assessment is critical to the entire care plan because everything is based upon what is found during assessment. we don't care about normal findings. normal findings mean that something is working as it is supposed to. we are interested in what isn't working correctly--what is abnormal--the indications and clues--the way to finding the nursing problems. assessment, for us nurses consists of:

• a health history (review of systems) - a __-year old male admitted for a blood glucose of 647 who sustained a small cut on his lip that developed into facial cellulitis (confirmed by ct scan) causing his whole face to become swollen. he has a medical history of type ii diabetes mellitus, bipolar disorder, is underweight for his height (6.0'/145 pounds) and has a history of smoking. he currently has an abscessed tooth located in the affected side (left or right?) of his face. he reports a recent history of burning both feet recently. nare swab and culture confirms mrsa. noteworthy labs upon admission 4 days ago were: k+ 5.7 (high), sodium 124 (low), alkaline phosphase 179 (high), alt 134 (high), ast 43 (high).
  
• performing a physical exam - the only assessment data that you really supplied was that he had 2+ pedal pulses (which is a normal finding), complained of pain when he opened his mouth to eat, and has only eaten 20% of lunch and dinner. with facial cellulitis i would have expected to see some kind of description of his face (where the erythema. warmth and tenderness of the skin is and any lymph node enlargement). is there any weeping and breakdown of the skin as tends to happen with cellulitis? is there any fever? chills? malaise? elevated wbcs? (symptoms of the infection) is he in isolation because of the mrsa? his underweight is a concern. a bad, abscessed tooth doesn't happen overnight. it takes time to happen. pain for something like this is assessed and measured by having the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain. did you assess his diet and what he typically eats? something is going on with his liver as well. did you look at these recently burned feet? was that a legitimate report he made? bipolar patients get depressed as well as manic. is he either? is he on medication for this condition? has he been taking the medication? as a smoker, his lung sounds should has been auscultated. long term smokers typically develop a hacking cough.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - nothing mentioned. adls-r-us. that's what we nurses do. adls should be one of your primary assessments of any patient.
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - if an elevated blood sugar and cellulitis is what the doctor admitted the patient for then that is one of the pathophysiologies you need to look at. you need to see the connection between diabetes, the high blood sugars and cellulitis. any infection is a complication of diabetes. the importance of learning about these conditions is that you need to know their pathophysiologies to understand the etiology for some of your nursing diagnoses. you also need to check your assessment to see if you overlooked or missed any signs and symptoms that could now prove to be significant when it comes to identifying the patient's nursing problems.
  
  • cellulitis
    
    • http://www.merck.com/mmpe/sec10/ch119/ch119b.html - cellulitis
      
    • http://www.fpnotebook.com/der/bacteria/clts.htm - cellulitis
      
    • http://www.fpnotebook.com/der/endo/skninfctnsindbtsmlts.htm - skin infections in diabetes mellitus
      
    • complication od cellulitis are: sepsis, local abscesses and lymphangitis
      

    [*]mrsa

    • http://www.medicinenet.com/mrsa_infection/article.htm - mrsa infection
      
    • http://www.webmd.com/skin-problems-and-treatments/understanding-mrsa-methicillin-resistant-staphylococcus-aureus - mrsa
      

    [*]type ii diabetes

    • http://www.merck.com/mmpe/sec12/ch158/ch158b.html - diabetes mellitus
      
    • http://www.fpnotebook.com/endo/dm/typ2dbtsmlts.htm - type 2 diabetes
      
    • complications of dm are ketoacidosis, cardiovascular disease, peripheral vascular disease, retinopathy, nephropathy, resistance to infection and depression
      

    [*]bipolar

    • http://www.merck.com/mmpe/sec15/ch200/ch200c.html - bipolar disorders
      
    • http://www.fpnotebook.com/psych/bipolar/bplrdsrdr.htm - bipolar disorder
      

    [*]smoking

    • http://www.merck.com/mmpe/sec05/ch045/ch045a.html - physical examination of the pulmonary system
      
    • http://www.fpnotebook.com/psych/cd/tbccstn.htm - smoking cessation
      

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - none listed. he has confirmed mrsa; is an antibiotic being given for this? what medical treatment other than drug treatment was ordered by the physician for the facial cellulitis that the nurses need to carry out? since he is a type ii diabetic, has he been on any medication to control his diabetes? with these elevated liver enzymes i wonder if he has been taking a medication that has a side effect that is hepatotoxic or if this patient is a regular drinker of alcohol.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - now that you've gone through and collected all kinds of data, you must make a list of the abnormal data. the abnormal data is indicative of the nursing problems. all that you have posted at this point, and i know there is more that you just haven't pinned down yet, is:

• facial cellulitis [needs specific description, e.g., red, swollen cheeks and eyes]
  
• small cut on his lip [needs specific description, e.g., 5 mm laceration on left corner of mouth]
  
• underweight [needs specific description, e.g., 6 foot, 100 pounds]
  
• only ate 20% of lunch and dinner
  
• c/o pain when he opens his mouth to eat [needs specific description, e.g., pain of 8 out of 10 when opening mouth to eat]
  

if you are wondering why the specific descriptions are so necessary for the data, it is because goals and evaluation later become dependent on comparisons with the original assessment data. with pain, for instance, goals are set to improve pain measured to an improved level above the 8 out of 10. whether the goal is met or not is based on evaluating what the patient states their level of pain is sometime later.

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - the abnormal assessment data is matched up with the defining characteristics of nursing diagnoses that apply. these will be actual nursing problems. in this case:

• impaired tissue integrity r/t traumatic injury, inflammation and uncontrolled blood glucose levels aeb [description of the facial cellulitis and the cut on the lip]
  
• acute pain r/t inflammation of facial skin and dental structures aeb [description of pain in face and mouth]
  
  • assessment and description of pain includes the following:
    
    • 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
        

  [*]imbalanced nutrition: less than body requirements r/t (unknown) aeb underweight [needs specific description, e.g., 6 foot, 100 pounds] and only ate 20% of lunch and dinner

  • this diagnosis would actually be sequenced first before the other two above. the problem. . .not enough data to formulate the etiology (r/t part of the statement) for the diagnostic statement. i believe the diabetes factors in here but i don't know how the doctor is approaching and treating it or if it is even under control at this point. there is also the dental problem that may be a contributing factor. and i am wondering about these liver enzymes and what is going on with them. did the doctor address any of this in his progress notes?
    

step #3 planning (write measurable goals/outcomes and nursing interventions). for the most part goals are what you predict will happen as a result of the nursing interventions you will order. the nursing interventions will take aim at those aeb items on the diagnostic statements. why? they are what make the nursing problem exist. it is logical that if we do something to improve or alter the signs and symptoms of the nursing problem then we are doing something about the problem. so, taking the first diagnosis impaired tissue integrity r/t traumatic injury, inflammation and uncontrolled blood glucose levels aeb [description of the facial cellulitis and the cut on the lip], i can formulate short and long term goals based on the aeb items. assuming there is no open skin and this is going to heal by primary intention, results should be seen within days. these goal statements are not properly written, but are only listed to give you an idea of what they can be. because the data you provided is incomplete and nonspecific i am at a great disadvantage in providing the goals and interventions.

• long term goal: in 2 weeks facial edema and erythema will be resolved.
  
• short term goal: in 24 hours skin erythema will lighten.
  
• interventions:
  
  • assess patient's facial area for redness, warmth, tenderness to touch, edema and tissue sponginess. [rationale: these are symptoms of the inflammatory response and evidence that the body is fighting off bacterial invasion.]
    
    
    
  • assess facial skin for any evidence of unblanching to touch or serous weeping [rationale: identification of a problem is necessary to getting the proper treatment that is needed.]
    
    
  • provide skin care as ordered by the physician. pat skin and do not rub it. [rationale: mechanical force contributes to the deterioration of the skin.]
    
    
  • give prescribed medications as ordered [rationale: the improvement of a medical condition will often depend on which medications are being given and why.]
    
    
  • make sure the patient understands the importance for contact precautions and hand washing between contact (this could depend on what has been actually been ordered for this patient) [rationale: contact precautions ensure that patient infections do not get passed to others.]
    
    
  • teach the patient about cellulitis, mrsa, the medications they are receiving and adverse effects [rationale: understanding the disease and how it is treated can improve the patient's compliance with medical treatment.]
    
    
  • teach the patient the signs and symptoms of sepsis and when to notify the physician [rationale: early detection of a problem will help to avoid a more serious complication later.]
    
    
  • contact the physician if the erythema increases or the patient becomes febrile [rationale: medical intervention may be necessary to treat an exacerbation of the infection.]
    
    

my first nursing diagnosis is risk for unstable blood glucose r/t lack of diabetes management, aeb sugar level 1 (severe deviation from normal).

1. it is an anticipated problem. this means it is a problem that doesn't exist yet. this patient has plenty of problems that exist. i found 3 and i suspect there are several other. the nursing problems are going to show up when the assessment improves.
   
   
2. because this is an anticipated problem there cannot be any aeb items. i have no idea what a
   sugar level 1 (severe deviation from normal)
   is. if the patient does have that (whatever it is) then it indicates the presence of an actual problem and there is probably a nursing diagnosis that we can match it to. it might have something to do with
   imbalanced nutrition: less than body requirements.
   
   
3. the man came in with facial cellulitis and mrsa and that can't be ignored. at the least, take a look at what the doctor has ordered (medications and treatments). what is the doctor treating? maybe we nurses treating along the same lines is a hint for the direction to go with the care plan. . .