Nursing DX with Elements

  1. Please help me with this assignment!

    I need to know if I'm thinking correctly or what I am missing. I'm suppose to list 3 complete nursing diagnosis based on the following information.

    The scenario is I have a 68 yr old man with a history of diabets, CAD, HBP and pulmonary emphysema. He comes with a foot wound and says that he attempted to cut out an ingrown toenail 5 days prior. He has been on anticoagulants for his CAD "to prevent strokes" and is also taking an adult aspirin each day. The affected toe is reddened with a necrotic center. There is also swelling of the foot. He lives alone and cares for himself with no family nearby.

    (I don't know what to do here as far at the ABC's? Should I list Ineffective Airway Clearance because of the emphysema??? I didn't because it wasn't a presenting problem but I feel like I'm going against the rules?)

    1. Ineffective Peripheral tissue perfusion r/t toe injury aeb necrosis & foot edema.

    2. Ineffective Health maintenance r/t lack of knowledge aeb medication administration and improper diabetic foot care. (I considered knowledge deficit, but didn't know how to add in everything he needs to learn????)

    2. Risk for Infection r/t open necrotic toe wound

    How can I be more specific and use more "medical terminology"?? My instructor really slammed me on my last assignment for being too vague and using incorrect elements.

    Please help me!!......

    I've thought about this so much my brain feels like jello

  2. Visit discobunni profile page

    About discobunni

    Joined: Nov '05; Posts: 69; Likes: 14
    Specialty: 1 year(s) of experience in NICU


  3. by   liljsmom02
    i suck at care plans but i will tell you this much. make sure your diagnosis matches your assessment info. i wouldn't choose knowledge deficent on med administration when it is quoted that the patient takes anticoags "to prevent strokes". you are contraindicating yourself by showing/knowing he knows what his meds are for and then claiming lack of knowledge.
    as far as ABC's/ they are always a priority but not always usable. stick with the issues at hand. maybe a risk for bleeding. i always try to use one psycho-social issue. we tend to be so focused with the illness we forget about the patient. sorry i couldn't be of much help
  4. by   discobunni
    I discussed with my instructor and here is what I came up with now:

    Impaired Tissue Perfusion r/t altered arterial flow aeb necrosis & edema

    Impaired Health Maintenance r/t lack of knowledge aeb improper diabetic foot care

    Impaired Skin Integrity r/t altered arterial flow aeb reddened toe w/necrotic center

    She wants the etiology behind the r/t with the defining characteristics as the aeb. My other instructor was a bit different on how she wanted these constructed.

    URG! So Frustrating! Maybe I'm finally learning something though!
    Oh, I didn't read into it enough.....the man "had been" taking an anticoagulant in the past, and now takes aspirin for his CAD. I thought he was taking both against dr. hard with these scenarios when you don't have the real patient there to clarify information! URG!

  5. by   zaccity
    Hey angela you tried your best. But always be very careful. consider what the pt. says than what you see, ask questions like do you have pain, discofort, SOBOE, and assess for v/s and this will give you your priority NANDA, otherwise from the scenerio you're right but the catch is you don't want this patient to develop an infection so
    riskfor infection is your # 1. gas exchange r/t p. emphysema
    impaired skin intergrity r/t
    alt in tissue perfusion r/t
    social isolation, loneliness etc.
    Always use your ABCs and stay calm and remain focused
  6. by   PsychNurseWannaBe

    We utilize 4 different formats to prioritize and cluster.

    ABCS (1st priorities)
    MAA-U-UR (2nd priorities)
    Third-level priority problems (3rd)
    Maslov's Heirarchy

    1st = Airway problems, Breathing problems, cardiac/circulation problems and Signs (vital)

    2. Mental status change, Acute pain, Acute urinary elimation problems, Untreated medical problems requiring immediate attention, Abnormal lab values, Risks of infection, safety, or security (for patient or others)

    3. Health probs that do not fit into the above catagories, such as lack of knowledge, activity, rest, family coping

    4. Then you can use Maslov's as a guide as well

    I would do it this way (just my opinion)

    Impaired Skin Integrity r/t altered arterial flow aeb reddened toe w/necrotic center

    Impaired Tissue Perfusion r/t altered arterial flow aeb necrosis & edema

    Impaired Health Maintenance r/t lack of knowledge aeb improper diabetic foot care

    But..don't get too hung up on this... once graduated, each facility does it differently!

    For example I would have to rephrase the second one to this: Knowledge deficit r/t poor self care AEB improper diabetic foot care. Personally I think it is a horse a piece. But that is why I would put your "impaired health maintence" last because it is a knowledge deficit. Just my opinion...God knows I'm not perfect LOL.

    Don't drive yourself nuts... keep it simple. I use Carpenito's book and it is very helpful.

    ~ Psych