Nursing diagnosis for patient with DM 2?

Lyndalee · Jan 9, 2009

Have you thought of "Impaired Skin Integrity" r/t circulatory impairment AEB draining wound? For the second dx, "Disturbed Body Image r/t physical changes AEB verbal concerns about amputation / altered view of body?

Do you refer to any Nursing dx books?? If Disturbed Body Image doesn't fit, safety is always an issue--A "Risk For" can be used--no r/t would be needed, so "Risk For Injury"(she is weak and probably can't ambulate alone)......hope this helps.

Daytonite, BSN, RN · Jan 9, 2009

there is a procedure to determining the nursing problems (nursing diagnoses) that a patient has. all professions that problem solve use a form of the scientific process to diagnose. doctors call it medical decision making; nurses call it the nursing process; i really don't know if plumbers or car mechanics have a name for it; the justice system has various names for the difference parts of the process. there is a definite sequence of events you should be following to come to some conclusions about what you want to do about this patient's care:

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

diabetes type ii - what are the complications?
wound on foot - has this wound been staged? what information do you know, or did you find out about wounds and how they heal? what did you find out about peripheral circulation in diabetics that lead to wounds and problems with healing of wounds in the lower extremities? what other assessment information did you collect about this patient's poor circulation of the lower extremities (pulses, skin color and warmth, edema, sensation of touch)?

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

open wound on left foot - this wound needs to be described. what are its measurements, depth? is there any redness of the skin surrounding the actual open area? is there any drainage? is there any odor?
verbal report of pain - pain needs to be measurable for a care plan. the patient should be asked to rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain. where is the pain? how long does it last? what triggers it? what relieves it or makes it worse? all of this information gives you assessment information that will not only help you diagnose the current problem, but also help you later assess whether any treatments you plan for this patient are working.
guarding behavior - what is guarding behavior for foot pain? i would describe exactly what the patient does.
feels weak - did you check her blood sugars and other labs? could this be related to her blood sugar? fatigue is a psychological symptom of grieving.
sorrow about the possibility of losing a limb - this is a very real psychosocial concern. if you were going to lose a foot, what kinds of things would you be worrying about (think about getting through all your daily activities as well as the psychosocial issue of how you would look to other people or how people would stare at you)?

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 - i see a couple of ways to go with this. the problem is that you didn't list any of the medical treatments that had been ordered as well, so i don't know what the medical focus of care is. i assume there is something being done to try to save this foot and treat this wound. i'm just guessing here, but is this patient on blood pressure or heart medications? could side effects of other medications be contributing to any of her other symptoms?

ineffective tissue perfusion, peripheral r/t impaired arterial circulation aeb [description of the open wound on left foot and any other assessment of the poor circulation]
- interventions will include measures to promote the best circulation of the lower extremities (i.e. elevating the legs), wound care and addressing the pain
- http://www.nursingquality.org/ndnqipressureulcertraining/module1/default.aspx
- http://www.hill-rom.com/usa/pdf/ctg285.pdf
- http://www.medicaledu.com/staging.htm
[*]acute pain r/t tissue destruction aeb verbal report of pain and guarding behavior [i've already suggested that this evidence needs to be more descriptive]
[*]psychosocial
- grieving r/t anticipated loss of the left foot aeb expressed feelings of sorrow about the possibility of losing her foot [physical symptoms of grieving include: fatigue, a hollow feeling in the chest and/or abdomen, sighing, hyperventilating, not eating, not sleeping or feeling of having a lump in the throat; there may be crying as well as anger, denial, and bargaining], or
- disturbed body image r/t perception of disfigurement aeb expressed feelings of sorrow about the possibility of losing her foot

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem - now you write your interventions. you address each piece of evidence (symptom) that you have to support each diagnosis. we treat symptoms just as the doctor does. so, for example, for pain in the foot that is a symptom of acute pain you will have interventions to treat this pain. you may give medication, provide emotional support by providing reassurance that measures are being taken to relieve the pain, you may reposition the foot every hour, encourage ambulation, or encourage distractive activities such as watching tv, reading, listening to music or playing puzzles.

ok, the ball is now in your court. this was just to get you started. you know way more about this patient than i do.