Please grade my very 1st care plan

[laogirlinSD]

please grade my very first care plan.

pt pmh of peripheral vascular disease, cad, hyperlipedemia (stable), non-healing right lower extremity ulcer since 2006 after hitting it with luggage, has been coming hospital 3 times a week for dressing changes. admitted directly from home (tj mexico) for wound vac/care prior to elective cabg.

i am focusing on the wound (primary diagnosis). pt does self care independently and uses wheelchair. pt is on morphine for pain, omeprazoie for gerd, baclofen for muscle spasm/pain, simvastatin for hyperlipidemia, aspirin for cardiac prophylaxis, nitroglycerin for chest pain, docusate for constipation, ferrous sulfate for low iron, senokot for constipation, magnesium hydroxide for constipation, zinc sulfate for supplemental, multivitamin w/ mineral for supplement, ascorbic for supplement, silver sulfadiazine for burn.

pt is on regular diet, and is hydrated. wound size: length 13cm x width 8cm x depth 0.2cm. tawny colored skin in gator area, large ulcer, base is errythematous with patches of sloughing yellow debris, minimal sanguineous drainage, no sign of infection, wound vac started day of admission.

this is the instruction and what i got:

a. select 3 nursing diagnoses that are appropriate to your patient's situation. make certain that your patient's etiologies for the nursing diagnoses correspond to what is suggested in ackley as appropriate etiologies. the etiologies must pertain to your patient. provide clarity and individualize your patient's etiologies by adding "secondary to." do not list more than 3 etiologies per nursing diagnosis.

list each diagnosis in the sections provided. the nursing diagnosis you are developing into your nursing care plan exercise should be listed as #3. it is only for this diagnosis that you must include signs and symptoms experienced by your pt.

refer to the functional patterns of nanda diagnoses and list the functional pattern for each nursing diagnosis.

assessment and nursing diagnosis phases

#1. functional pattern: elimination

nursing diagnosis label: constipation

etiologies and "secondary to:"

a. insufficient physical activity secondary to pressure ulcer stage 3/4.

b. recent environmental changes secondary to pt's statement of "the thought of being away from home and misses wife's cooking."

c. pain medications secondary to relieve neck pain and ulcer

#2. functional pattern: pain/ discomfort

nursing diagnosis label: acute pain

etiologies and "secondary to:"

a. tissue destruction, exposure of nerve secondary to ulcer

b. debridement of wound secondary to exudate

c. psychological secondary to pt's verbal report of pain

#3. functional pattern: skin/ tissue integrity

nursing diagnosis label: impaired tissue integrity

etiologies (related to):

a. physical immobilization secondary to pressure ulcer stage 3/4 on right lower extremity

b. environment moisture secondary to dressing changes

c. impaired oxygen transport secondary to peripheral vascular disease

signs: irregular shape wound: 13cm x 8cm x 0.2cm with yellow slough, sanguineous exudate; skin maceration

symptoms: patient's report of non-healing wound after hitting it with luggage.

b. completion of the nursing care plan below requires that you refer to:

• patient readiness assessment and teaching strategies for implementation
  
• ackley book for outcome and intervention ideas; nursing care worksheet for dependent orders that pertain to the identified nursing diagnosis

planning phase:

goal: during stay in hospital wound will decrease in size and decrease or improvement in sanguineous drainage, macerated skin and sloughing.

outcome:

1. demonstrated understanding of plan to heal tissue and prevent injury.

2. describe measures to protect and heal the skin, including wound care.

3. experience a wound that decrease in size and has increase granulation tissue.

4. monitor size and amount of drainage coming from wound.

implementation phase:

1. identify and explain risk factors and etiology of pressure ulcers to patient.

2. do wound care/dressing changes as ordered: change wound vac every m/w/f. maintain sterililty with each care.

3. verify protein intake to provide nutrients necessary for tissue repair.

4. maintain adequate nutrition hydration.

5. assess patient's current phase of wound healing and stage of injury during wound care/ dressing changes and chart it.

6. encourage patient to avoid cigarette smoking and other high risk activity.

7. encourage patient to keep weight off right leg and use wheelchair for mobility.

evaluation phase:

unable to evaluate:

but i would look for: pt's understanding of wound care, nutrition intake, wound remain free of infection, decrease in exudate and maceration, wound decrease in size, and sign of granulation tissue.

ok i am so tire. please give me your thoughts. i want to do well on this assigment because it's a major part of my grade. thanks!

[Daytonite, BSN, RN]

since this patient has peripheral vascular disease, cad, hyperlipedemia (stable) i would have diagnosed them with ineffective tissue perfusion, peripheral. that gives you the etiology of "c. impaired oxygen transport secondary to peripheral vascular disease ". the defining characteristics for this diagnosis include delayed healing of a skin wound which is what is going on with this patient (the wound enlarged instead of getting smaller and healing). review the defining characteristics for this diagnosis ob this website: [color=#3366ff]ineffective tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral. using this diagnosis also puts it at the top of your list of nursing diagnoses because it primarily has to do with oxygenation of the tissues. since you want your care plan to focus on this wound it looked odd that your third diagnosis (impaired skin integrity) was the primary focus. also, impaired skin integrity doesn't cover wounds that have extended down into the subcutaneous layers of the skin.

i've had 3 stasis ulcers. if all you did for me was identify my risk factors and etiology of pressure ulcers (mine weren't due to pressure and neither were this patient's--his was due to trauma--he hit his leg with a suitcase), verify protein intake to provide nutrients necessary for tissue repair, maintain hydration, stop smoking and keep weight off the affected leg, my poor sores would have healed on their own without your help. i had to go on disability because i was put on ordered bedrest where i kept my leg elevated above the level of my heart. the wound itself burned and hurt so bad i wanted to scream. i was off of work for weeks! peripheral edema was contributing to the problem so the elevation of the leg helped the edema and circulation to the leg. it was also when we found i was insulin resistant (pre-diabetic) and that high blood sugars were impeding the healing. one ulcer had taken over a year to heal. i had unna wraps, pressure dressings, ace wraps and jobst stockings. i was given diuretics. i was on antibiotics the entire time the wounds were open and draining. the vascular circulation to some extremities is so bad that hyperbaric oxygen treatments are done as a treatment modality in an attempt to heal them before fem-pop bypass surgery or amputation is undertaken. the skin of the area where these ulcers were is shiny, smaller compared to the other leg and discolored. i told my doc the other day he will never see me in a dress because of this.

• http://ezinearticles.com/?stasis-dermatitis---healing-venous-ulcers&id=1653842
  
• http://www.nlm.nih.gov/medlineplus/ency/article/000834.htm
  
• http://www.medicaledu.com/default.htm - wound care network
  
• http://uwmedicine.washington.edu/patientcare/loc/vascularsurgery/conditions/venousstasisulcer/
  
• http://www.visualdxhealth.com/adult/stasisulcervenousulcer-selfcare.htm

you need to have more interventions that are going to promote optimum circulation to this extremity. this will give this boo boo a better environment in which to heal--it already has poor circulation and atherosclerosis working against it. you are not going to cure the vascular disease, cad, or hyperlipedemia. you have to work with it. there is a lot of patient teaching because this can happen to him again. my boo boos were due to simple cat scratches from my cats which had happened a million times before. now, every bump or scratch gets close attention, ace wraps and i increase my diuretics until it has healed.

[laogirlinSD]

Thank You Daytonite. After reading your post it makes sense and i went back and make corrections.

I find that i enjoy reading every posts of yours..it's so full of information. You are so wise. i want to acquire those knowledges too. I am taking baby little steps for now.