need help with nursing diagnosis pleeeez

[turtlehead]

So I'm working on my first care plan as a first semester nursing student. I need 5 nursing diagnoses rated from highest priority to lowest written in 3 step form [problem, related to (r/t) , as evidenced by (AEB)]. Then I need outcome identification, interventions, and evaluations.

My patient--64 years old, caucasian, female, married. 23 hour admission for surgery to correct shoulder impingement caused by bony spurs on the acromion. Laparoscopic shoulder decompression was performed to remove the bone spurs and reshape the acromion to free up subacromial space. I met her just hours before her discharge. She was pain free and anxious to go home. She has her arm temporarily in a sling (a few days at most) and was given some exercises to do by her surgeon.

I've had a difficult time coming up with 5 diagnoses. Please tell me what you think. The thing is...what struck me more about her condition was not even related to the surgery--it was that when I interviewed her she told me she was very healthy, never had a health issue. She is very overweight, has NIDDM, HTN, and hyperlipidemia. She sees these as not problems because she is on meds that control these issues. I incorporated this into my care plan--need some feedback.

So here's what I've come up with after an embarrassingly long contemplation:typing:eek:

Nursing Diagnoses-

1) Self-care deficit, bathing/hygiene, dressing/grooming, toileting related to impaired physical mobility as evidenced by external device (sling) on left arm and physician's orders for limited motion.

2) Risk for infection related to invasive procedure (arthroscopic shoulder decompression surgery) and concurrent medical condition of NIDDM as evidenced by sutures on shoulder and patient's statement that "I've noticed that I don't heal from cuts or bruises like I used to. It took a month for a little cut on my arm to heal last month."

3) Risk for impaired skin integrity related to altered physical mobility secondary to external device (arm sling), altered circulation and altered sensation secondary to chronic disease process (NIDDM) as evidenced by physician ordered arm sling, post-operative movement restrictions for 4-6 weeks, and patient's hand on affected side appearing paler than rest of body and feeling cold to the touch.

4) Ineffective health maintenance related to deficient knowledge regarding treatment and control of disease processes (hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus) as evidenced by patient's report that "I don't have a single health problem other than being a little overweight."

5) Imbalanced nutrition: more than body requirements related to lack of knowledge of relationship between diet and the disease process (hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus) as evidenced by patient's weight in relationship to her height (5'7" 210 lbs.) as well as her statements throughout our interview: "I don't like vegetables. I like pasta-fettucine alfredo is my favorite. I like to eat it with warm rolls and lots of butter. I like desserts a little bit too much. Sometimes I get positively exhausted after meals. I think you should be able to eat what you want. My grandmother lived to be 106. My mother lived to 89. I think genetics determines more than anything you do in life."

[vashtee, RN]

She's already had surgery, so she has impaired skin integrity - this would not be a "risk for" diagnosis, I don't think.

I wonder if "risk for renal failure r/t poor compliance with diabetic diet" is a nursing diagnosis? :)

[turtlehead]

That's a good question...definitely a concern...I'll look it up in NANDA for formatting. Thanks for caring.

[Daytonite, BSN, RN]

follow the nursing process and problem solve this:

step 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 - how did she get bone spurs on her acromion? did she say? how has having these spurs altered her functioning in her daily life already? did she say? most orthopedic surgeons discuss exactly how the patient is going to be immobilized as a result of the surgery and discusses it with the patient so they can prepare ahead. did you talk with the patient about this. you were aware that he had already given her exercises and told she would need to wear a sling. will she be able to drive? lift? carry grocery bags? how does she keep her niddm under control? does she have any evidence of complications? hyperlipidemia and htn are complications of dm. she may also have symptoms of atherosclerosis. htn is a complication of obesity. what are other complications of obesity. she is at risk for a lot of serious health problems including stroke and mi.

• shoulder impingement caused by bony spurs on the acromion
  
• laparoscopic shoulder decompression to remove the bone spurs and reshape the acromion to free up subacromial space
  
• overweight
  
• niddm
  
• htn
  
• hyperlipidemia

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - i picked out some symptoms from your diagnostic statements that i felt were important. diagnoses are based upon patient symptoms; they are the evidence that prove the existence of the problem

• patient's hand on affected side appearing paler than rest of body and feeling cold to the touch
  
• movement restrictions (arm will be in a sling--a few days at most; was given some exercises to do by her surgeon)
  
• sutures on shoulder
  
• "i've noticed that i don't heal from cuts or bruises like i used to. it took a month for a little cut on my arm to heal last month." (this may be due to poor control of the niddm)

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -

ineffective tissue perfusion, peripheral r/t impaired circulation secondary to niddm aeb patient's hand on affected side appearing paler than rest of body as well as feeling cold to the touch and patient's statement "i've noticed that i don't heal from cuts or bruises like i used to. it took a month for a little cut on my arm to heal last month."

imbalanced nutrition: more than body requirements related to lack of knowledge of relationship between diet and the disease process (hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus) as evidenced by patient's weight in relationship to her height (5'7" 210 lbs.) as well as her statements throughout our interview: "i don't like vegetables. i like pasta-fettucine alfredo is my favorite. i like to eat it with warm rolls and lots of butter. i like desserts a little bit too much. sometimes i get positively exhausted after meals. i think you should be able to eat what you want. my grandmother lived to be 106. my mother lived to 89. i think genetics determines more than anything you do in life."

this is where this would be sequenced if you use it. the only related factor for this diagnosis is "excessive intake in relation to metabolic need". that is pretty much the only way you get overweight. when you go on about "of knowledge of relationship between diet and the disease process (hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus)" you've gone into another nursing diagnosis:

deficient knowledge, specify

. so, why not just use that?

impaired physical mobility r/t surgical intervention and prescribed movement restrictions aeb immobilization of shoulder and presence of sutures.

self-care deficit, bathing/hygiene, dressing/grooming, toileting related to impaired physical mobility as evidenced by external device (sling) on left arm and physician's orders for limited motion.

the problem here is that i added a diagnosis of impaired physical mobility which you can keep if you want. if you keep it, you need to dump this diagnosis because they would just be repetitious. if you keep this one, you need to re-word "physician's orders for limited motion". that is a treatment prescribed by the doctor and not assessment data. with self-care deficits you need to list what she can't do, i.e. "can't button her blouse, can't wipe herself after after potty, can't draw up insulin with one hand--that kind of stuff.

impaired tissue integrity r/t surgical intervention aeb presence of sutures on shoulder.

ineffective health maintenance related to deficient knowledge regarding treatment and control of disease processes (hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus) as evidenced by patient's report that "i don't have a single health problem other than being a little overweight."

this is pretty much a teaching or management of the patient's overall care diagnosis because they have failed at either or both. so, i can accept your related factors. but, how does the statement like "i don't have a single health problem other than being a little overweight" support a knowledge deficit and control of disease process as the etiology of this? it sounds more like she refuses to take responsibility for her part in her obesity plays in her medical problems. her obesity has a lot to do with her health. i would rewrite this as

ineffective health maintenance r/t inability to take responsibility for meeting basic health practices aeb patient's report that "i don't have a single health problem other than being a little overweight."

the old "head buries in the sand" defense.

risk for delayed surgical recovery r/t elevated blood glucose

risk for infection related to invasive procedure (arthroscopic shoulder decompression surgery) and concurrent medical condition of niddm as evidenced by sutures on shoulder and patient's statement that "i've noticed that i don't heal from cuts or bruises like i used to. it took a month for a little cut on my arm to heal last month."

the interventions for this could be merge with the ones for the risk for delayed surgical recovery. either way, this patient is at risk for a post op infection because of her diabetes and poor glucose control. wounds take forever to heal when blood glucose is not kept under control and they can get infected very easily because bugs love the sugar. i think you should merge the two risk factors and use

risk for delayed surgical recovery r/t elevated blood glucose and postop infection.

risk for impaired skin integrity related to altered physical mobility secondary to external device (arm sling), altered circulation and altered sensation secondary to chronic disease process (niddm) as evidenced by physician ordered arm sling, post-operative movement restrictions for 4-6 weeks, and patient's hand on affected side appearing paler than rest of body and feeling cold to the touch.

this is not a risk, it is a reality. the skin was broken the minute the surgeon's scalpel touched it. just a point i want to make. . .because "risk for" diagnoses are anticipated problems that do not yet exist they cannot have any symptoms or evidence of them. again, the sling on the arm is a treatment.

these are the 5 i think you should have and 4 are actual problems:

1. ineffective tissue perfusion, peripheral r/t impaired circulation secondary to niddm aeb patient's hand on affected side appearing paler than rest of body as well as feeling cold to the touch and patient's statement "i've noticed that i don't heal from cuts or bruises like i used to. it took a month for a little cut on my arm to heal last month."
   
2. impaired physical mobility r/t surgical intervention and prescribed movement restrictions aeb immobilization of shoulder and presence of sutures.
   
3. impaired tissue integrity r/t surgical intervention aeb presence of sutures on shoulder.
   
4. ineffective health maintenance r/t inability to take responsibility for meeting basic health practices aeb patient's report that "i don't have a single health problem other than being a little overweight."
   
5. risk for delayed surgical recovery r/t elevated blood glucose and postop infection.

[turtlehead]

Thank you so much. You really overextended yourself and put so much into your reply--bless you for your selflessness and charity.

[haitiangk92]

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