PLEASE HELP!!! Does my care plan need changes?

Daytonite, BSN, RN · Oct 14, 2008

you asked if your care plan needed changes. i made comments about changes to what you posted in purple. i also added some comments at the end.

impaired gas exchange

related to

ventilation perfusion imbalance, alterations in alveolar-capillary membranes, & alveoli hypoventilation

the patient does not have any medical disease that supports altered alveolar-capillary membranes. altered alveolar-capillary membranes means that the actual anatomy of the alveoli membrane has been permanently changed due to disease. this happens in conditions like copd. this is not happening here. what is alveoli hypoventilation? never heard of it. i wouldn't use something i never heard of or couldn't explain.
- better: ventilation perfusion imbalance

manifested by (s&s): this diagnosis is primarily used if the patient has either hypoxia or hypercarbia. therefore, your symptoms need to reflect and support that. is this patient really hypoxic?

hypoxia (sao2 90% considered hypoxia? that's a pretty good sao2 result.
lethargy/fatigue - this is not a symptom of hypoxia and doesn't belong here
diminished lung sounds - this is not a symptom of hypoxia and doesn't belong here
dyspnea
sob - this is the same as dyspnea
labored breathing - this is the same as dyspnea
bilat pulmonary interstitial edema cxr 09/26/08 - how is this proving the patient is hypoxic? this would not be a symptom of hypoxia.

better: impaired gas exchange r/t ventilation perfusion imbalance m/b dyspnea.

even better: activity intolerance r/t imbalance between oxygen supply and demand and weakness m/b a decrease in sao2 to as low as 70% with exertion, tachycardia along with the decrease in sao2 and dyspnea. with this more appropriate diagnosis, your goal and interventions need to be changed.

nanda nursing diagnosis:

impaired skin integrity

related to (etiology)

poor circulation, altered sensation, fluid shift, & tissue inflammation

what do you mean by fluid shift? edema? inflammation of the tissues does not cause the skin to break open. do you know the process of maceration of the tissues and then their invasion with yeast? what conditions help a yeast infection to thrive? and, didn't this patient have fevers, a symptom of sepsis on admission? fevers cause system wide generation of body heat which also contributes to the growing conditions for yeast. those are etiologies of the skin breakdown in the groin and thigh
- better: poor circulation, altered sensation, moisture, humidity, hyperthermia and swelling of tissues

manifested by (s&s):

l shin & r great toe ulcer
bilat 2+ edema - this is not evidence of skin breakdown and does not belong with this diagnosis
red, warm, & cracked skin below the knees - "warm"th is not a symptom of skin breakdown
bilat yeast infection in folds b/w groin and thighs - to say "yeast infection" is medical diagnosing. just describe what the rash looks like.
bitlat pedal tingling/numbness (pvd) - this is not evidence of skin breakdown and does not belong with this diagnosis

better: impaired skin integrity r/t poor circulation, altered sensation, moisture, humidity, hyperthermia and swelling of tissues m/b l shin & r great toe ulcer, red and cracked skin below the knees, and reddened weeping skin in the folds of the groin and thighs.

even better: impaired skin integrity r/t poor circulation, altered sensation, moisture, humidity, hyperthermia and swelling of tissues m/b 4mm x1mm open ulceration on left shin, open ulcer on the r great toe, reddened weeping skin in the folds of the groin and thighs and red and cracked skin below the knees.

planning

-

a. goal (patient will...) understand the plan to heal skin & prevent reinjury as evidence by verbal repeat after teachings. b. interventions with rationale: interventions target the symptoms (the data/evidence that supports the existence of this problem. what interventions do you have for the ulcer on the shin, the ulcer on the toe, and that nasty red skin in the folds of the groin. interventions are of 4 types:

assess/monitor/evaluate/observe (to evaluate the patient's condition)
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)

where are your actual patient care interventions besides turning the patient? skin inspection, diet supplements, assessment and teaching the patient to turn are all very nice, but what are you, the nurse, doing to encourage the healing of all this broken skin?

1.encourage

patient to inspect skin

on a daily basis and report any signs or symptoms of infection; fever, chills, redness, swelling, heat, pain, etc

a.early assessment & intervention help prevent serious problems from developing

2.

teach patient

to self turn q 2 hrs & to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury

a.turning & the use of effective pressure-reducing devices significantly prevent skin breakdown

3.

demonstrate to patient

wound/skin care @ times of dressing changes; cleansing, topical ointment application & wet-to-moist dressing changes

a.demonstration enhances comprehension & patient adherence

4.encourage patient to stick with recommended diet plan created by dietitian (1800 kcal/day, increase protein intake, supplemental vitamins, 2g na diet w/ 1.5 l fluid restriction) - the rationale for increasing protein and vit c is to

promote healing

.

a.aids in healing & maintains good health & skin integrity.

5. get the area in the folds of the groin dry. wash it daily with mild soap and rinse well. place dry toweling or a dry washcloth in the folds to prevent skin-on-skin contact and to promote moisture removal. apply any antiinfective cream that was ordered by the physician.

6. how will you address the cracked skin below the knees?

evaluation /revision

1.met

a.patient verbally repeated back the signs & symptoms of infection & acknowledge the importance of seeking medical advise/treatment when symptoms arise - patient already has sepsis and a yeast infection

2.met

a.patient complied to teachings, self turned on own q 2 hrs, followed pt orders (oob to chair x3), and used pillows to free float heels on shift

3.met

a.i verbally explained each step of the dressing change @ the time of dressing change & answered all questions he had at the time to enhance comprehension

4.met

a.place where he resides (eskaton) makes his meals & he says he is on the diabetic meal plan there. verbally said he wants to continue with diet to loose weight

nanda nursing diagnosis:

acute pain

related to (etiology)

tissue/skin damage secondary to inflammation/fluid shift

inflammation proceeds in this sequence of events: redness, heat, swelling, pain. the fluid shift, which i presume you mean to be swelling is part of the inflammatory process that leads up to the pain. as the tissues swell they push on the surrounding nerve endings which is why the patient gets pain with inflammation. that is the pathophysiology of inflammation.
better: inflammatory process

manifested by (s&s):

verbalized pain rate 6/10 on 1-10 pain scale.
c/o head/ache and ble pain
l shin & r great toe ulcer - this is not evidence of pain
bilat 2+ edema - this is not evidence of pain
red, warm, & cracked skin below the knees - this is not evidence of pain

better: acute pain r/t inflammatory process m/b patient's pain rated 6/10 on 1-10 pain scale in the head and ble.

planning and interventions/rationales are ok

-----------------------------------

you have some unaccounted for abnormal assessment data that didn't get diagnosed which you might want to take into consideration:

ineffective tissue perfusion, peripheral r/t impaired blood flow secondary to peripheral vascular disease pvd and diabetic neuropathy m/b skin of ble change color to bluish purple when dependent, bue/ble cold to examiner's touch, bilateral 2+ edema of ___, and bilateral numbness and tingling in feet.

which wound was thought to be the source of the sepsis? the cellulitis, the shin ulcer or the ulcer on the great toe? or, didn't they know? that wasn't made clear in the data you presented. where was the patient's cellulitis? the lower legs? that wasn't described either. also, you didn't list any of the patient's medications or treatments other than mentioning the wet to moist (not wet to dry?) dressings for ?? open skin/ulcer. so, his diabetes, heart problem and gerd couldn't be addressed. the crackles in the lungs are probably related to his heart problem and hypertension. and why was the foley catheter inserted? to keep the area of cellulitis clear of urine? is he incontinent? that brings up the issue of self-care deficits. with an amputation, cellulitis, spinal stenosis and a degenerative lumbar intervertebral disc this man is probably limping when he walks. that makes him have impaired physical mobility.

the diagnoses i would list for this patient based on the information provided and in priority order are:

activity intolerance r/t imbalance between oxygen supply and demand and weakness m/b a decrease in sao2 to as low as 70% with exertion, tachycardia along with the decrease in sao2 and dyspnea.
ineffective tissue perfusion, peripheral r/t impaired blood flow secondary to peripheral vascular disease pvd and diabetic neuropathy m/b skin of ble change color to bluish purple when dependent, bue/ble cold to examiner's touch, bilateral 2+ edema of ___, and bilateral numbness and tingling in feet.
impaired skin integrity r/t poor circulation, altered sensation, moisture, humidity, hyperthermia and swelling of tissues m/b 4mm x1mm open ulceration on left shin, open ulcer on the r great toe, reddened weeping skin in the folds of the groin and thighs and red and cracked skin below the knees.
acute pain r/t inflammatory process m/b patient's pain rated 6/10 on 1-10 pain scale in the head and ble.

kgh31386, BSN, MSN, RN · Oct 14, 2008

that goes to show you...a quick glance vs. detailed assessment haha. she brings up good points

AquariusAngl916 · Oct 18, 2008

i'm stuck! :cry: any feedback for the areas in red? thank you.

nanda nursing diagnosis:

activity intolerance

related to (etiology)

imbalance between oxygen supply and demand and weakness

manifested by (s&s):

decrease in sao2 to as low as 70% with exertion, tachycardia & dyspnea

planning

a. goal (patient will...) ???

b. interventions with rationale:??? (i need 4)

nanda nursing diagnosis:

ineffective tissue perfusion, peripheral

related to (etiology)

impaired blood flow secondary to peripheral vascular disease pvd and diabetic neuropathy

manifested by (s&s):

skin of ble change color to bluish/purple when dependent, bue/ble cold to touch, weak 1+ radial/pedal pulses, bilateral 2+ edema of ble, and bilateral numbness and tingling in feet

planning

a. goal (patient will...) demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, & a balanced intake & output

(is this goal realisitc & specific enough?)

b. interventions with rationale:

1. assess & note pedal pulses, capillary refill, skin color, temperature, texture and the presence of pain, ulcers & edema in the extremities.

a. assess severity of arterial/venous insufficiency

2. elevate legs when lying in bed, discourage sitting/standing for long periods of time or wearing constrictive clothing & crossing legs

a. elevation increases venous return, helps decrease edema, and can help heal venous leg ulcers

3. explain the importance of good foot care. teach the client to wash and inspect the feet daily. recommend client to wear padded socks & good fitting shoes

a. ischemic feet are very vulnerable to injury; meticulous foot care can prevent further injury

4. i need 1 more intervention

nanda nursing diagnosis:

impaired skin integrity

related to (etiology)

poor circulation, altered sensation, moisture, humidity and swelling of tissues

manifested by (s&s):

4mm x1mm open ulceration on left shin, open ulcer on the r great toe, reddened weeping skin in the folds of the groin and thighs and red and cracked skin below the knees

planning

a. goal (patient will...) understand the plan to heal skin & prevent reinjury as evidence by verbal repeat after teachings.

b. interventions with rationale:

1. encourage patient to inspect skin on a daily basis and report any signs or symptoms of infection; fever, chills, redness, swelling, heat, pain, etc

a. early assessment & intervention help prevent serious problems from developing

2. teach patient to self turn q 2 hrs & to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury

a. turning & the use of effective pressure-reducing devices significantly prevent skin breakdown

3. demonstrate to patient wound/skin care @ times of dressing changes for ulcers; cleansing, topical ointment application & wet-to-moist dressing changes

a. demonstration enhances comprehension & patient adherence

4. get the area in the folds of the groin dry. wash it daily with mild soap and rinse well. apply anti-infective cream that was ordered by the physician.

a. ( i still need to fill out the rationale for this intervention)

5. encourage patient to stick with recommended diet plan created by dietitian (1800 kcal/day, increase protein intake, supplemental vitamins, 2g na diet w/ 1.5 l fluid restriction)

a. increasing protein and vit c promote healing

evaluation /revision

1. met

a. patient verbally repeated back the signs & symptoms of infection & acknowledge the importance of seeking medical advise/treatment when symptoms arise

2. met

a. patient complied to teachings, self turned on own q 2 hrs, followed pt orders (oob to chair x3), and used pillows to free float heels on shift

3. met

a. i verbally explained each step of the dressing change @ the time of dressing change & answered all questions he had at the time to enhance comprehension

4. met

a.

place where he resides (eskaton) makes his meals & he says he is on the diabetic meal plan there. verbally said he wants to continue with diet to loose weight

Daytonite, BSN, RN · Oct 18, 2008

I'm curious. . .what criticisms and suggestions did the classmate who reviewed the original submitted care plan make about it?

AquariusAngl916 · Oct 18, 2008

She didn't make any adjustments to my nursing diagnosis's at all. Just fixed some grammical errors and typo's. In all honestly I didn't have a whole lot of faith in getting a lot out of swithting our care plans with another nursing student. I'm just so nerouvs about picking the 3 most important nursing diagnosis's for my patient and having specific/realistic goals.

AquariusAngl916 · Oct 19, 2008

I'm still thinking Impaired Gas Exchange is a better fit than Activity Intolerance and here's my rationale. On 9/26 there was evidence of bitlet pulmonary interstitial edema in his x-ray. My day of care for this patient was 10/3. I think he's just still on the road to recovering from that. An x-ray done 2 days after the first x-ray 9/28 did show no evidence of pulmonary edema, but then again I don't think the patient just bounces back quick from that. Is this assumption right? My instructor gave the same exact feedback. She too also said it was due to the fact he was still covering from that...

]NANDA Nursing Diagnosis:

]Impaired gas exchange

]

]Related to (etiology)

]Ventilation perfusion imbalance, alterations in alveolar-capillary membranes, & alveoli hypoventilation

]Manifested by (S&S):

]SaO2

]Lethargy/fatigue]

]Diminished lung sounds

]Dyspnea

]Bilat pulmonary interstitial edema CXR 09/26/08

]Planning

]a. Goal (patient will…) demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by SaO2 > 90% & absence of symptoms indicating increased respiratory distress (restlessness/confusion/LOC, nostril flaring, á] HR, â]/á] RR, use of accessory muscles) through out shift

]b. Interventions with Rationale:

]1. ]Administer O2 (2L/min via NC) to increase SaO2 levels > 90% per M.D. order

]a. ]Provides for adequate oxygenation

]2. ]Assess/trend oxygenation levels by monitoring continuous pulse oximetry, RR, HR, presence of any crackles or wheezes in lungs, ABG’s if available, skin color, cap refill, & changes in orientation & behavior (restlessness & agitation)

]a. ]Know patient’s oxygenation level baseline to be able to note any changes

]3. ]Position patient in upright, high-Flower’s position to facilitate ventilation/perfusion matching

]a. ]High-Fowler’s position allows for optimal diaphragm excursion

]4. ]Teach deep breathing using incentive spirometer

]a. ]R]educes alveolar collapse

]Evaluation/Revision

]1. ]Met

]a. ]Patient’s SaO2 levels stayed above 90% majority of the time through out shift. He had frequent episodes of hypoxia on exertion & @ rest. Told patient to take deep breathes when he heard his continuous pulse oximetry alarm set off

]2. ]Met

]a. ]Checked on patient Q 30 mins & monitored for signs/symptoms of decreased oxygenation levels (restlessness / confusion / LOC, nostril flaring, á] HR, â]/á] RR, use of accessory muscles). No changes from baseline.

]3. ]Met

]a. ]HOB was set @ 45 degrees at all times. Checked Q 30 mins while implementing intervention #1.

]4. ]Met

]a. ]Taught patient how to use incentive spirometer, encouraged patient use @ least 5 times / hour. Set goal of 1500ml for the day. Patient showed willingness & interest.

]NANDA Nursing Diagnosis:

]Ineffective Tissue Perfusion, peripheral

]Related to (etiology)

]Impaired blood flow secondary to Peripheral Vascular Disease PVD and Diabetic Neuropathy

]Manifested by (S&S):

]Skin of BLE change color to bluish/purple when dependent, BUE/BLE cold to touch, weak 1+ radial/pedal pulses, bilat 2+ edema of BLE, and bilat numbness and tingling in feet

]Planning

]a. Goal (patient will…) demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, & a balanced intake & output

]b. Interventions with Rationale:

]1. ]Assess & note pedal pulses, capillary refill, skin color, temperature, texture and the presence of pain, ulcers & edema in the extremities.

]a. ]Assess severity of arterial/venous insufficiency

]2. ]Elevate legs when lying in bed, discourage sitting/standing for long periods of time or wearing constrictive clothing & crossing legs

]a. ]Elevation increases venous return, helps decrease edema, and can help heal venous leg ulcers

]3. ]Explain the importance of good foot care. Teach the client to wash and inspect the feet daily. Recommend client to wear padded socks & good fitting shoes

]a. ]Ischemic feet are very vulnerable to injury; meticulous foot care can prevent further injury

]NANDA Nursing Diagnosis:

]Impaired skin integrity

]

]Related to (etiology)

]poor circulation, altered sensation, moisture, humidity and swelling of tissues

]Manifested by (S&S):

]4mm x1mm open ulceration on left shin], open ulcer on the R great toe, reddened weeping skin in the folds of the groin and thighs and red and cracked skin below the knees

]Planning

]a. Goal (patient will…) understand the plan to heal skin & prevent reinjury as evidence by verbal repeat after teachings.

]b. Interventions with Rationale:

]1. ]Encourage patient to inspect skin on a daily basis and report any signs or symptoms of infection; fever, chills, redness, swelling, heat, pain, etc

]a. ]Early assessment & intervention help prevent serious problems from developing

]2. ]Teach patient to self turn Q 2 hrs & to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury

]a. ]Turning & the use of effective pressure-reducing devices significantly prevent skin breakdown

]3. ]Demonstrate to patient wound/skin care @ times of dressing changes for ulcers; cleansing, topical ointment application & wet-to-moist dressing changes

]a. ]Demonstration enhances comprehension & patient adherence

]4. ]Get the area in the folds of the groin dry. Wash it daily with mild soap and rinse well. Apply anti-infective cream that was ordered by the physician.

]a.

]5. ]Encourage patient to stick with recommended diet plan created by dietitian (1800 kcal/day, increase protein intake, supplemental vitamins, 2g Na diet w/ 1.5 L fluid restriction)

]a. ]Increasing protein and Vit C promote healing

]Evaluation /Revision

]1. ]Met

]a. ]Patient verbally repeated back the signs & symptoms of infection & acknowledge the importance of seeking medical advise/treatment when symptoms arise

]2. ]Met

]a. ]Patient complied to teachings, self turned on own Q 2 hrs, followed PT orders (OOB to chair X3), and used pillows to free float heels on shift

]3. ]Met

]a. ]I verbally explained each step of the dressing change @ the time of dressing change & answered all questions he had at the time to enhance comprehension

]4. ]Met

]Place where he resides (Eskaton) makes his meals & he says he is on the Diabetic meal plan there. Verbally said he wants to continue with diet to loose weight

Daytonite, BSN, RN · Oct 19, 2008

goals reflect the predicted outcome of the interventions, so there need to be interventions to make sure the goals can be achieved.

i really am not happy that you copied things that i wrote in critique for you word for word into this care plan. that makes it my work, not yours. it may get you by with this assignment, but what will you do for the next ones? i am concerned that you are understanding how i made my decisions. what if you are asked to defend these choices by your instructor?

nanda nursing diagnosis:

activity intolerance

related to (etiology)

imbalance between oxygen supply and demand and weakness

manifested by (s&s):

decrease in sao2 to as low as 70% with exertion, tachycardia & dyspnea

planning

goal: patient will ambulate ___ feet and pulse and respiration will return to normal within 3 minutes by ____.

1. increase patient's distance of ambulation by 10 feet each day-

gradually increasing activity will reduce cardiac tissue hypoxia

2. monitor vital signs before, during and after ambulation -

adaptation and tolerance to increases in activity will be manifested by the heart and lungs

3. plan short periods of activity sandwiched between one to two hours of rest -

rest provides minimum energy expenditure

4. as the patient increases their daily exercise teach them to monitor themselves for symptoms of abnormal responses to activity to report to their physician: confusion, chest pain, dizziness, faintness, failure of their pulse to return to normal within 3 minutes after ambulation -

abnormal responses are an intolerance to increased activity

nanda nursing diagnosis:

ineffective tissue perfusion, peripheral

related to (etiology)

impaired blood flow secondary to peripheral vascular disease pvd and diabetic neuropathy

manifested by (s&s):

skin of ble change color to bluish/purple when dependent, bue/ble cold to touch, weak 1+ radial/pedal pulses, bilateral 2+ edema of ble, and bilateral numbness and tingling in feet

planning

a. goal (patient will...) demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, & a balanced intake & output

(is this goal realisitc & specific enough?)

patient will correctly position lower extremities so they are elevated above the level of the heart while in bed by the end of the shift.

b. interventions with rationale:

1. assess & note pedal pulses, capillary refill, skin color, temperature, texture and the presence of pain, ulcers & edema in the extremities.

a. assess severity of arterial/venous insufficiency

2. elevate legs above the level of the heart when lying in bed, discourage sitting/standing for long periods of time or wearing constrictive clothing & crossing legs

a. elevation increases venous return, helps decrease edema, and can help heal venous leg ulcers

3. explain the importance of good foot care. teach the client to wash and inspect the feet daily. recommend client to wear padded socks & good fitting shoes

a. ischemic feet are very vulnerable to injury; meticulous foot care can prevent further injury

4. i need 1 more intervention

4. teach patient to avoid risks that can cause potential aggravation of symptoms such as exposure of lower extremities to the cold atmosphere and ingestion of caffeine or nicotine

a.

knowledge increases the likelihood of patient compliance