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Discussion

Please help me with my first care plan!!

Hi, I just finished my third week of clinical and my first care plan is due next week. This my first semester so everything is still trying to fit in my head and make a little sense.

My patient, 82 yrs. female was admitted for having a gangrene foot. She is not a diabetic but has a vascular problem. She is scheduled to have surgery this coming Friday and the doctor is still not sure if it'll be a debri or amputation. I did not get to see the wound but my primary nurse described it to be red and purple on the big toe and 5th toe.

She was an amazing cheery person and besides the foot there wasn't much wrong with her. She does have hypertension and history of GI ulcer. Incredibly independent, she took a shower everyday in the morning while there.

My diagnosis is Risk for Infection.

But here is my problem: I know I can't use a medical term to describe like saying "risk for infection related to gangrene foot"

If you guys can help my mind think here because I'm having a big time freeze! It is due next Tuesday and need to get this started soon!!

Thank you so much!

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    I don't think "Risk for Infection" is where you want to go. Those are for conditions that may develop, but haven't necessarily occurred yet. Like, a surgical patient has risk for infection due to the surgery itself, or another patient may have risk for infection secondary to immunosuppression. For your patient, I think maybe "Ineffective Tissue Perfusion" may be a diagnosis. When I start doing my care plans, I look in the book and try to find the biggest thing that my patient may have. Then you look at the actual diagnosis and see if the conditions they've layed out actually fit what you've seen. I don't have my nursing dx book in front of me, but "Delayed Wound Healing" or "Risk for Falls" if your patient is on antihypertensives or has walking aids like canes. If it's your first care plan, I would talk to your instructor to narrow down your options and maybe get a few ideas.

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    Risk of infection r/t compromized circulation.

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    Fear r/t possible loss of extremity

    Ineffective Tissue perfusion: peripheral r/t obstruction of arterial flow.

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    • Author

    Thank you so much for the input! Looking a little deeper into my care plan book I actually came across Risk for impaired skin integrity r/t poor circulation. I will bring this up to my professor tomorrow and hopefully she will help me and not say that I have to do this on my own :(

    Again, thank you

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