Need help on care plans!

[ctine05]

hi, i'm a first semester nursing student and i have been having trouble trying to do my care plans this week.i usually get them done without any trouble, but for some reason i just cannot think of diagnoses for my patient:confused:.once i get the diagnosis down i'm usually good.i'll give you some information on my patient....

my patient was admitted to the emergency room after waking up with severe foot pain.she had an emergency pcta, sfa, and popliteal done.(percutaneous transluminal coronary angioplasty, superficial femoral artery and popliteal artery)after assessment and diagnostic testing it was confirmed that patient had an ischemia to the left lower limb as a result of arteriosclerosis and required ptca, sfa & popliteal surgery to restore circulation to the extremity.she has a sore on her left foot that was confirmed as cellulitis.wound care was done on her left foot this morning. patient wound measures 1.5mm x 1mm (length and width) with the depth

skin break down.

patient has a medical history of htn, dm, vascular dementia, gastroparesis, tia, cva, gerd, anemia, gastritis, cad, djd, bipolar disorder and pyuria. patient's surgical history includes bilateral carotid aterectomy. patient denies any history of smoking tobacco or alcohol consumption.

vitals- t-97.8, bp 95/63, pulse ox 96%, pulse 69, her blood sugar was 116.(she is diabetic)

lab values- glucose-163, co2-20, wbc-2.9, hemo-10.8, hemat-32.9.

she rates her pain a 5/10.it is aching when sitting and sharp when applying pressure.

we have to do a care plan on the neurosensory system and cardiopulmonary.

i was thinking acute pain related to inflammation of ulceration wound site as evidenced by patient demonstrating facial grimacing when applying pressure to her lower left extremity and patient stating "my pain is a 5/10."-nuerosensory.i'm not sure if that would be a correct diagnosis?

i cannot think of anything for cardiopulmonary....possibly , impaired tissue integrity related to altered circulation..would that be one?

any help is greatly appreciated, i'm having such a tough time on these!

[tnbutterfly - Mary, BSN]

Moved to Nursing Student Assistance forum for more response.

[ctine05]

Impaired tissue integrity related to

decreased oxygen and nutrient supply to the skin and subcutaneous tissue associated with reduced blood flow as evidenced by disruption of skin surface and blisters on patient’s lower left extremity.....could this be a cardiopulmonary diagnosis?

[Esme12, ASN, BSN, RN]

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

and some links you will find helpful

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

[pockunit, ADN, RN]

Esme12, you fit quite nicely into Daytonite's shoes. That was a great description.

[nurseprnRN, BSN, RN]

i suggest the op look up diabetes, care, complications, and physiological effects, and therein will find a lot of useful data to plug in to the information esme gives. dm gives you a lot of problems, and you are seeing a lot of them right there with this patient.

[tarheelsu]

Look up DM in your med-surg book and see what ND are common for it.

For neurosensory think about any problems with pain or sensation. Many diabetics have issues with perhipheral neuropathy where they can't feel their feet very well, so they get foot ulcers that don't heal because they don't know they're there.

For cardiopulmonary, think of anything that has to do with circulation. Tissue perfusion, blood pressure, etc.