Yep another help with careplan post!!

[MisStake]

This is only my second care plan ever, so bear with me. I need help formulating a nursing diagnosis for my patient. He is ESRD, Type II diabetic, CHF, Dementia patient, MRSA+ in his blood, admitted for fever and weakness. His GFR is 6, he is on dialysis 3x weekly. (At his last treatment they removed 800 ml fluid). Creatinine 9.3, BUN 90. Electrolytes all normal. He had extremely low urine output, 50 ml over an 8 hour shift. He's not oriented to anything except himself. He is unable to get out of bed due to weakness and pain in his left hip but can turn side to side. He has a good appetite and is eating normally (renal and ADA diet). Blood sugars all ok. He is neither dehydrated nor fluid volume excess (no edema, no crackles in lungs, etc.)

I am leaning toward risk for impaired skin itegrity r/t decreased mobility, metabolic impairment and diabetes. Any other suggestions? I honestly don't know where to start!!

[Daytonite, BSN, RN]

a care plan is about determining the patient's problems and developing strategies to either improve, stabilize or support their deterioration. we use the nursing process, which is our primary tool, to help us. here is how it can do that in care planning:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
   • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

• it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
  
• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration

  [*]interventions are of four 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)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

from what you posted, i can use the nursing process to do this:

step #1 assessment - look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - i can't help but think you missed some symptoms. if this patient is diabetic with heart problems, what kind of medications is he on? what was his cardiac and lung assessment? if 800cc of fluid was removed during dialysis, where was it hidden in his body? look up the signs and symptoms of esrd, diabetes, chf, dementia and fever. fever is a symptom of infection. diabetics are prone to infections. esrd is a complication of diabetes. this is all related and this all sounds more and more complicated and not as simple as it might be. one of the problems with infections in people with chronic disease is that they tend to have low grade fevers which masks the infection, one of the cardinal symptoms of an infection.

• esrd
  
• type ii diabetic
  
• chf
  
• dementia patient
  
• mrsa+ in his blood
  
• fever and weakness
  
• on dialysis 3x weekly
  
• creatinine 9.3/bun 90

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• low urine output, 50 ml over an 8 hour shift
  
• unable to get out of bed due to weakness
  
• pain in his left hip
  
• not oriented to anything except himself
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• fluid volume (excess or deficit)
  
• impaired physical mobility
  
• (acute or chronic) pain
  
• (acute or chronic) confusion
  

step #3 planning - write measurable goals/outcomes and nursing interventions - these are based upon the abnormal assessment data items that you are using to support the nursing diagnoses you chose in step #2/part 2.

i think there is a lot of data you might have missed. this is why you need to go back to step #1 and read about this patient's diseases. i took care of many of this type of patient and they require a lot of nursing care which is a big hint that there are problems. assess his ability to perform his adls. esrd patients often have poor cognitive and thinking ability since their systems are muddied with toxins that the dialysis can't completely remove. this also creates an underlying nausea that many have almost constantly if you ask them about it. they will tell you that they just don't feel quite right. they often also have dizziness.