Please Help with Formal Care Plan prioritizing ND!!

elizabeth321 · Apr 29, 2010

sorry I would have to be paid a lot of money to read all that and comment...good luck

monkeesilly · Apr 29, 2010

How many do you need to choose and you need a CBG reading to state any problems with the pts DM.

itsmejuli · Apr 29, 2010

You've stated your goals, but what are your nursing interventions?

iamshane · Apr 29, 2010

i need all 5 of them..i have to hit all the themes such as nutrition, integ, cardio/resp, rest, self concept, fluid/electrolyte, self concept, elimination: solid and urine...i have a total of like 35 diagnosis but these first five are the most important. the pt's bg was 156 at the time of fingerstick.

my interventions were super long so i think it scared people off...here are they are tho...if you care to read them all

the first nd got cut off..

unstable blood glucose level r/t changes in physical health status, infectious process, inadequate blood glucose monitoring, and medical management aeb weakness, fatigue, poor muscle tone and non-healing wound of the right foot.

1.a

i. perform fingerstick glucose testing before and after meals. unstable blood glucose is often associated with failure to perform testing on a regular schedule.

ii. note times when short-acting and long-acting insulins are administered. these factors affect timing of effects and provide clues to potential timing of glucose instability.

iii. check injection sites. insulin absorption can vary from day to day in healthy sites and is less absorbable in lypohypertrophic (lumpy) tissues.

iv. review client’s dietary program and usual pattern & compare with recent intake. this helps identify deficits and deviations from therapeutic plan, which may precipitate unstable glucose and uncontrolled hyperglycemia.

v. weigh daily or as indicated. assess adequacy of nutritional intake—both absorption and utilization.

vi. auscultate bowel sounds & note reports ofabdominal pain and bloating, nausea, or vomiting. hyperglycemia and fluid and electrolyte disturbances decrease gastric motility and function resulting in gastroparesis, affecting choice of interventions.

vii. identify food preferences, including ethnic and cultural needs. incorporating as many of the client’s food preferences into the meal plan as possible increases cooperation with dietary guidelines after discharge.

viii. observe for signs of hypoglycemia—changes in loc, cool and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, and shakiness. once carbohydrate metabolism resumes, blood glucose level will fall, and as insulin is being adjusted, hypoglycemia may occur. if client is comatose, hypoglycemia may occur without notable change in loc. this potentially lifethreatening emergency should be assessed and treated quickly per protocol. note: type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished.

ix. monitor laboratory studies, such as serum glucose,acetone, ph, and hco3–. blood glucose will decrease slowly with controlled fluid replacement and insulin therapy. with the administration of optimal insulin dosages, glucose can then enter the cells and be used for energy. when this happens, acetone levels decrease and acidosis is corrected.

x. review types of insulin used, such as rapid, short-acting, intermediate, long-acting, and premixed. different insulin types affect timing of effects and a combination is often used to maintain optimal blood glucose level.

1.b

i. demonstrate and teach client to wipe with an alcohol pad at the lateral side of their finger before fingerstick.. wiping the site of puncture prior to pricking helps prevent infections.

ii. teach client to prick the lateral side of the finger and to correctly apply blood at the appropriate spot on the device. fingertips tend to have more nerve endings and can be painful. therefore, the lateral side of the finger is used as a common site for puncture.

iii. teach client to place and hold an alcohol pad at the puncture site. this helps prevent infection.

teach client to record blood glucose values properly. self-monitoring of blood glucose four or more times a day allows flexibility in self-care, promotes tighter control of serum levels, such as 60 to 130 mg/dl before meals and after meal peak level of less than 180 mg/dl, and may prevent or delay development of long-term complications (ada, 2007).

iv. teach client to clean the smbg device weekly or as needed. this helps to prevent infection.

1.c

i. teach/demonstrate to client the various sites (abdomen, buttocks, thighs, and arms; however, the abdomen provides the fastest absorption and is the most common site) that can be used for injection insulin. this gives the client alternatives if an injection site cannot be temporarily used.

ii. teach client to use the same general location at the same time each day. this acclimates the body for optimal insulin absorption and utilization.

iii. teach client to rotate within each injection site. insulin is less absorbable in lypohypertrophic (lumpy) tissues.

iv. teach client to light grasp a fold of skin and inject at a 90-degree angle. aspiration for blood is not needed. (a thin patient may need to pinch the skin and inject at a 45-degree angle to avoid im injection). folding of skin helps to avoid an im injection which has a faster absorption rate and is not used for routine insulin use.

2.a

i. assess wound with each am dressing change and record findings on wound care flow sheet used by hospital. providing an assessment establishes if progression is being made toward goals. using standard documentation discourages the use of subjective descriptions and allows staff to communicate objective wound assessments using the same frame of reference.

ii. perform aseptic dressing changes along with wound debridement, and application of prescribed topical antibiotics q12h per physician’s order. dressing wound debridement, and application of antibiotics must be performed on schedule and in the prescribed manner to facilitate healing and reduce chance of a systemic infection. aseptic technique confines the infection and prevents the entry of pathogens into other possible breaks in skin.

iii. monitor for signs of systemic infection as follows:

- systemic infection/septicemia:

o temperature > 38° c or

o heart rate > 90 beats/min

o respiratory rate > 20 breaths/min or paco2

o wbc count > 12,000 cells/μl or 10% immature form

regular skin inspection and assessment enables early detection of damage and infection. infected wounds will require more of both medical and nursing interventions.

iv. assess the client's nutritional status; refer for nutritional consultation and/or institute use of dietary supplements. inadequate nutritional intake places the client at risk for skin breakdown and compromises healing. optimizing nutritional intake, including calories, fatty acids, protein, and vitamins, is needed to promote wound healing.

2.b

i. provide demonstrations, diagrams, and handouts to teach client skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. early assessment and intervention help prevent the development of serious problems

2.c

i. teach client and family members to wash hands before proceeding with wound care. washing hands helps with prevent further infections.

ii. teach client and the person to be performing the wound care the proper steps and techniques in removing the dressing, cleaning the wound, applying prescribed topical, and applying a new dressing as outlined by the physician and wound care rn. proper and timely wound care will help progress towards wound healing.

iii. teach the client use of pillows and pressure-reducing devices to prevent further injury. the use of effective pressure-reducing cushions helps with protection and injury prevention.

3.a

i. check the dorsalis pedis, posterior tibial, and popliteal pulses bilaterally. if unable to find them, use a doppler stethoscope and notify the physician immediately if new onset of pulses is not present. diminished or absent peripheral pulses indicate arterial insufficiency with resultant ischemia.

ii. note skin color and feel the temperature of the skin. skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signal arterial obstruction, which is an emergency that requires immediate intervention.

iii. check capillary refill of the toes. nailbeds usually return to a pinkish color within 2 to 3 seconds after nailbed compression

iv. do not elevate the legs above the level of the heart. leg elevation decreases arterial blood supply to the legs.

v. keep the client warm but do not apply heat. keep extremities warm to maintain vasodilation and blood supply. heat application can easily damage ischemic tissues.

3.b

i. stress the importance of not smoking, carefully controlling a diabetic condition, controlling hyperlipidemia and hypertension, and reducing stress. all of these risk factors for atherosclerosis can be modified to help prevent decrease in circulation.

ii. teach client to avoid exposure to cold, to limit exposure to brief periods if going out in cold weather, and to wear warm clothing. keeping the body warm promotes vasodilation and increased blood flow.

4.a

i. assess the client's nutritional status; refer for nutritional consultation for actual caloric count and institute use of dietary supplements if necessary. inadequate nutritional intake places the client at risk for skin breakdown and compromises healing. optimizing nutritional intake, including calories, fatty acids, protein, and vitamins, is needed to promote wound healing and build the immune system to fight possible infections.

ii. monitor food intake; specify proportion of served food that is eaten (i.e. 25%, 50%). documenting intake aids in properly adjusting the client’s diet to prevent malnutrition.

iii. weigh patient weekly. during aggressive nutritional support, patient can gain up to 0.5 pound/day.

iv. evaluate client's laboratory studies (serum albumin, serum total protein, serum ferritin, transferrin, hemoglobin, hematocrit, vitamins, and minerals). an abnormal value in a single diagnostic study may have many possible causes, but serum albumin less than 3.2 g/dl was shown to be highly predictive of mortality in hospitals.

4.b

i. monitor state of oral cavity (gums, tongue, mucosa, teeth). provide good oral hygiene before and after meals. good oral hygiene enhances appetite; the condition of the oral mucosa is critical to the ability to eat. the oral mucosa must be moist, with adequate saliva production to facilitate and aid in the digestion of food.

ii. provide companionship at mealtime to encourage nutritional intake. mealtime usually is a time for social interaction; often clients will eat more food if other people are present at mealtimes.

iii. assess for the influence of cultural beliefs, norms, and values on the client's nutritional knowledge. what the client considers normal dietary practices may be based on cultural perceptions.

iv. validate the client's feelings regarding the impact of current lifestyle, finances, and transportation on ability to obtain nutritious food. validation is a therapeutic commu-nication technique that lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship

4.c

i. review and reinforce the basic four food groups, as well as the need for specific minerals or vitamins patients may not understand what is involved in a balanced diet.

ii. review and reinforce the importance of maintaining adequate caloric intake; an average adult (70 kg) needs 1800 to 2200 kcal/ day; patients with burns, severe infections, or draining wounds may require 3000 to 4000 kcal/day.

iii. review and reinforce foods high in calories and protein. foods high in calories and protein promote weight gain and nitrogen balance.

5.a

i. asses the client’s ability, readiness to learn, and previous knowledge r/t health preservation, medication management, disease states and community resources. learning best occurs when learners are motivated and when instruction is tailored to the client’s cognitive ability (olinzock, 2004).

ii. create an environment of trust by listening to concerns and being available. rapport and respect need to be established before client will be willing to take part in the learning process.

iii. select a variety of teaching strategies, such as demonstrating needed skills and having client do return demonstration, incorporating new skills into the hospital routine. use of different means of accessing information promotes information retention into the hospital routine.

iv. tailor the delivery of instruction to the client’s cognitive level by using visual aids and accessible word choices. clients with lower literacy benefit from well-tailored materials (dewalt, et al., 2004).

5.b

i. explain the normal blood glucose range and how it compares with client’s level, the type of diabetes the client has, and the relationship between insulin deficiency and a high glucose level. provides knowledge base from which client can make informed lifestyle choices.

ii. teach client the symptoms of hypoglycemia—weakness, dizziness, lethargy, hunger, irritability, diaphoresis, pallor, tachycardia, tremors, headache, and changes in mentation—and explain causes. may promote early detection and treatment, preventing or limiting occurrence. however, approximately 30% of insulin-dependent clients are asymptomatic when hypoglycemic. note: early-morning hyperglycemia may reflect the “dawn phenomenon,” indicating need for additional insulin, or the somogyi effect, requiring a decrease in medication dosage and/or change in diet such as bedtime or hour of sleep (hs) snack.

iii.teach and reinforce to client acute and chronic complications of the disease, including visual disturbances, neurosensory and cardiovascular changes, renal impairment, and hypertension. awareness helps client be more consistent with care and may prevent or delay onset of complications.

iv. review signs and symptoms requiring medical evaluation—fever, cold, or flu symptoms; cloudy, odorous urine; painful urination; sensory changes with pain or tingling of lower extremities; changes in blood sugar level; and presence of ketones in urine. prompt intervention may prevent development of more serious or life- threatening complications.

5.c

i. instruct the patient to do the following (once the wound is healed and in the absence of a foot ulcer):

• inspect your feet daily, especially the area between the toes.

• wash your feet daily with lukewarm water and soap. dry thoroughly.

• apply moisturizing cream to your feet after bathing. do not apply to the area between your toes.

• change into clean cotton socks every day.

• do not wear the same pair of shoes 2 days in a row, and wear only shoes made of breathable materials, such as leather or cloth.

• purchase shoes that have plenty of room for your toes. buy shoes later in the day, when feet are normally larger. break in new shoes gradually.

• check your shoes for foreign objects (nails, pebbles) before putting them on. check inside the shoes for cracks or tears in the lining.

• wear socks to keep your feet warm.

• trim your nails straight across with a nail clipper. smooth the nails with an emery board.

• see your physician or nurse immediately if you have blisters, sores, or infections. protect area with a dry, sterile dressing. do not use adhesive tape to secure dressing.

• do not treat blisters, sores, or infections with home remedies.

• do not smoke.

• do not step into the bathtub without checking the temperature of the water with your wrist or thermometer. optimal temperature is 95° f (35° c).

• do not use very hot or cold water. never use hot water bottles, heating pads, or portable heaters to warm your feet.

• do not treat corns, blisters, bunions, calluses, or ingrown toenails yourself.

• do not go barefooted.

• do not wear sandals with open toes or straps between the toes.

• do not cross your legs or wear garters or tight stockings that constrict blood flow.

• do not soak your feet.

foot care management prevents or delays complications associated with peripheral neuropathies and circulatory impairment, especially cellulitis, gangrene, and amputation. note: studies show that approximately 15% of all clients with diabetes will develop a foot or leg ulcer during the course of the disease. also, 50% of all nontraumatic lower extremity amputations occur in people with diabetes. prevention is therefore critical.

RNTutor, BSN, RN · Apr 29, 2010

hello guys,
i am new to this forum but i've seen some awesome help which i utilized in my other care plans but i really need some help with prioritizing my formal care plan. my patient had a right foot wound with necrosis measure 2x.5x.75in. the patient is a diabetic with renal failure and is on dialysis. here are my top 5 nd,noc, and nic. it's quite long but any help would be super appreciate...it's due on friday!!
priority nursing dx #1: unstable blood glucose level
1.a ct will maintain blood glucose level w/in satisfactory range throughout shift: daytime blood sugar levels b/t 80 and 120 mg/dl and bedtime sugar levels b/t 100 and 140 mg/dl.
1.b ct will demonstrate proper techniques for self-monitoring of blood glucose by end of shift.
1.c client will demonstrate proper injection of insulin by end of shift.

sounds okay, but in your description of the pt you didn't mention that her blood glucose levels have been unstable. does she need help getting them under control? what is the r/t and aeb for this dx?

priority nursing dx #4: imbalanced nutrition: less than body requirement r/t loss of appetite s/t depressed moodaeb weight loss, weakness, and poor muscle tone.

she has depressed mood? depending on how significant it is, that could be a pretty important nursing dx. think about hoplessness, or ineffective coping. how might that have affected her ability to care for herself, or to learn new information?

priority nursing dx #5: deficient knowledge of dm management r/t lack of exposure and unfamiliarity with information resources aeb presence right foot ulcer.
5.a client will demonstrate desire to learn and ask questions by end of shift..
5.b client will verbalize understanding of disease process and potential complications by day 3 of hospital stay or prior to discharge.
5.c client will demonstrate at least 3 proper foot care instructions by day 3 of hospital stay or prior to discharge.

i might add a little to this dx because the presence of right foot ulcer does not necessarily indicate that she has a knowledge deficit. i mean, how many pts do you see that know exactly what they should be doing, just don't do it for whatever reasons? if she knows what to do, but didn't do it because she felt overwhelmed, hopeless, etc, then another nursing dx might be better. or if you stick with knowledge deficit, then make sure to add an aeb that supports the lack of exposure/unfamiliarity (i.e. was just recently diagnosed dm, or hasn't had transportation to go to dr appts, etc).

and like another post said, make sure you add the nursing interventions!! it's great to have goals, but if we don't say how we're going to accomplish them, then what's the point? :)

iamshane · Apr 29, 2010

thanks for your comments! i appreciate it very much!