Need help with my first care plan

  1. I had a pt tonight with cellulitis. He speaks not English, so I could not get any subjective information. I know the client is in pain because of the types meds he is on and I read the chart from the primary nurse. Now, since I was unable to use pain as my diagnosis, I decided to do impaired immobility r/t progression of disease. He had gangrene on his toe, wearing a special slipper to prevent him from falling. Can someone tell me if it make sense.
    His Vital signs were wnl, high HCT, hb, and platelets.

    Thank you
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    About NaomieRN

    Joined: Nov '05; Posts: 1,883; Likes: 95


  3. by   Daytonite
    hi, futurenurse35!

    even though the patient couldn't speak english there should have been other symptoms you could observe. one of the things you need to do a little research on for this care plan is the various pain assessment guides. now, you know this patient has pain. you can't ignore that in your care planning which is what you are wanting to do! there are a number of pain rating scales that you should learn about that could be used for this patient including several that use pictures. we were just discussing the subject of patients who don't speak english in my legal class last evening. one of your nursing interventions for his (acute or chronic) pain diagnosis will be to find someone who speaks the patient's language to help you communicate and establish how to use a pain scale assessment with him.

    your patient also has gangrene on his toe. why? what is the mechanism of action that would cause him to have gangrene? is this man a diabetic? is or was a smoker? got peripheral vascular disease? or, peripheral arterial disease? there are three potential nursing diagnoses lurking here: ineffective tissue perfusion, impaired skin integrity and chronic pain. cellulitis is an inflammation of the tissues. is this inflammation just around the gangrenous toe or involving the entire leg? how much edema is present? think about the effect of a lot of swelling on the internal tissues and circulatory organs (veins and arteries) of an extremity already having compromised circulation.

    with limited mobility and pain this patient is going to have all kinds of self-care deficits. what did your assessment and the nursing admission indicate that he was able and unable to do for himself? care plan the deficits.

    with an elevated hematocrit, hemoglobin and platelets, what is the patient at risk for? this indicates he has altered clotting mechanisms. possible diagnoses for this are ineffective protection (the man is at risk for a stroke, thrombus or embolism, not to mention infection and sepsis because of the gangrene) and (risk for) deficient fluid volume (dehydration?)

    go back through all the medical diagnoses you have for this patient. look up the signs and symptoms of each of his medical problems here on this site using the search box at the top left of each page: (family practice notebook)
    then, compare what they are telling you the signs and symptoms of his diseases are with the actual data you were able to collect from his medical record. every one that matches are symptoms you need to use to help put together nursing diagnoses for him. combine those actual symptoms with the nursing data you collected about him. all the abnormal data is what you use to determine what nursing diagnoses to use for your care plan.

    only after listing out all this actual data (symptoms, defining characteristics) can you really start to look at some nursing diagnoses. i've given you some suggestions as to where to start looking. before choosing a nursing diagnosis, make sure that you have at least one, and hopefully a few more, symptoms or defining characteristics that go with each diagnosis. you determine that from looking in a nursing care plan book or nursing diagnosis hand book. if you have neither, there are a limited number of nursing diagnoses you can view online at two of the careplan constructor sites. here are links:

    • - this is a list of the nursing diagnoses that are available for viewing on the website. just click on one for the accompanying page to come up.
    • - you want to know which nursing diagnosis you want to look for, or have a specific symptom the patient is experiencing in mind. in the area where is says "start new plan" you want to click on the alphabetic range that the diagnosis or symptom you are looking for will be and click on those letters. a page of links will come up. clicking on symptoms will give you a list of potential nursing diagnoses. clicking on a nursing diagnosis will take you to that particular nursing diagnosis page.
    if you have not already looked at the information at these sites on allnurses, i strongly suggest you do so:

    if you have a nursing diagnosis book i also suggest that you read through the early chapters of what the nursing process is and how to determine a nursing diagnosis. you always group your abnormal data (or symptoms) that you got from your assessment and use them to determine your nursing diagnoses. you do not use the patient's medical diagnoses to figure out what his nursing diagnoses are going to be.

    i've given you a start and a lot to begin re-thinking your approach to this care plan. post another question if you need more help with this and i will help you put this together.
  4. by   Daytonite
    here is a link to a page of links to pain assessment tools. check them out. one or more would be appropriate for your patient.
  5. by   NaomieRN
    Thank you so much, you are simply the best!!!