Published Jul 27, 2009
LA_Style
4 Posts
I NEED HELP!!!!!
Im doing a careplan for a patient and I need help.
Im so confused... My patient has facial cellulitis and was admitted for a blood glucose of 647. HX: DM2, Bipolar, smoker, underweight. (6.0'/ 145pnds) with 2+ fetal pulses. Recent hx. PT states he burned both feet recently and has recently suffered a small cut on his lip that caused his whole face to progressively swell. The CT confirms cellulitis in the face. The patient also has a abscessed tooth located in the affected side. Nare swab confirms MRSA. The patient is eating but, oly ate 20% ofe lunch and dinner when I took care of him. He C/O pain when he opens his mouth to eat. other labs upon admission 4 days ago were K 5.7, sodium 124, alkaline phosphase 179, ALT 134, AST 43. Right now, the glucose is under control and new labs are pending. My first nursing diagnoses iis risk for unstabel blood glucose r/t lack of diabetes management, AEB sugar level 1 (severe deviation from normal).
Now, I have no idea what the second nursing DX should be. I need STG and LTG with 5 interventions with rationals.. Can someon please help me? I have been at this for 2 days now. Thanks.
Daytonite, BSN, RN
1 Article; 14,604 Posts
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:
[*]mrsa
[*]type ii diabetes
[*]bipolar
[*]smoking
[*]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:
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:
[*]what triggers the pain
[*]what relieves the pain
[*]observe their physical responses
[*]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
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.
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my first nursing diagnosis is risk for unstable blood glucose r/t lack of diabetes management, aeb sugar level 1 (severe deviation from normal).
Thank you so much.. I am revising my careplan based on what you have shared here. That information gave me a pretty solid foundation to build off of. THANK YOU!!!! I will post more info on this patient when i get out of class so that u can get the complete picture, i.e ,meds and lab values.