Nursing Dx for type 2 DM pt

[jamieousn]

Hi there, im a nursing student and I need a little help. I am writing a nursing process paper on a pt that has type 2 DM. He has decubiti heel ulcers infected with MRSA and peripheral neuropathy in his legs. I want my priority dx to be about skin integrity issues (r/t decr circulation, incr blood gluc levels, decr mobility, and decr sensation). I think NANDA only has a risk for diagnosis for skin integrity.....im not exactly sure what dx I should be using???? the other dx was infection r/t wounds but again, it is a risk for dx and the pt already has the infection. Does anyone have any ideas on a priority dx? thanks!

[Daytonite, BSN, RN]

you must understand that a care plan is your written process of how you problem solved the patient's nursing problems. you are, in effect, putting in writing your critical thinking process. you should be incorporating the nursing process which is our problem solving process to do that. your nursing process paper will be, most likely, presented in an essay form, but all the elements of the nursing process, and in the sequence that they occur, will make their appearance. begin by organizing the structure of your presentation:

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)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

  [*]always sequence actual nursing problems before potential (risk for) or anticipated problems

  • use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
    
  • http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs - maslow's hierarchy of needs
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's (bathing, dressing, mobility, eating, toileting, and grooming), look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - since this is a paper you need to present information about these three medical conditions. don't forget to include the medications and treatments the patient is receiving and any side effects or likely complications of them. it would be appropriate to detail how physicians determine these mediacak diagnoses and what tests are commonly order to not only test for them, but to monitor their progress.

• type 2 dm
  
• decubiti heel ulcers infected with mrsa
  
• peripheral neuropathy in his legs
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - from all the assessing you do you will discover a lot of abnormal data about the patient. nursing problems are always based upon abnormal data which becomes the evidence you will have to support their existence. without this list of abnormal data (symptoms) you cannot begin to determine what your patient's nursing problems are. you want to use a diagnosis of impaired skin integrity which would be appropriate since the patient has ulcers on his heels. but you need assessed data for them. heel ulcers are open wounds. describe them. what does the skin look like? is there any drainage present? is there any pain? without this information interventions and goals cannot be developed either. mrsa is a medical diagnosis and there is no nursing diagnosis relative to that. break mrsa down into its symptoms and complications. are any of those a nursing problem for this patient? we know mrsa is a nursing problem for the staff, but this is a care plan about the patient so stay focused. what about the peripheral neuropathy in the legs? other than being one of the probable etiologies for the heel ulcers, what other problems is the patient going to have as a result of this complication of diabetes? (i have it, so believe me, i know and it doesn't just affect the lower legs!) what would be the nursing diagnosis for that? with heel ulcers does this patient have mobility issues? how does he walk? get to the bathroom to toilet? is he incontinent? has the neuropathy affected his ability to know when he has to pee or poop? has the neuropathy given him problems with his digestion? there are so many actual problems this patient could have. what other complications of diabetes might the patient be at risk for?

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 - since you provided no data i can provide almost no help here

• impaired skin integrity r/t impaired circulation, impaired metabolism, impaired sensation, pressure over bony prominences and physical immobilization aeb [?? need data for the decubiti on the heels] - note: impaired skin integrity is used for stage i and ii decubitus ulcers. impaired tissue integrity is used for stage iii and iv decubitus ulcers. the reason is based in the definitions of these nursing diagnoses. this is another reason why you need to assess the wound (it's depth)
  

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 support the existence of the problem - your overall goal is always aimed to alter or change something about the problem

[jamieousn]

yeah i realized after I sent this that it should be tissue since it is a stage 3!!thanks for your help, i really appreciate it....im starting to piece it together a bit better now. these papers are killing me!!