60 yo female, acute osteomyelitis in R great toe

[lwandel]

Hello all :)

I am working on another care plan that is due Monday morning. My pt is a 60 year old female with an admitting dx of Acute Osteomyelitis in great toe of R foot.

I need 3 nsg dx- thinking of Imbalanced Nurtrition: more than, Acute pain r/t injury and fatiggue r/t anemia.

Allergies: Penicillin, ibuprofen, vancomycin, promethazine, ciprofloxacen

Relevant Health History:

History of morbid obesity (63", 347.8lb)

diabetes mellitus type2

Asthma

History of GAVE Syndrome (gastric antral vascular ectasia, aka watermelon stomach; acute or chronic gastrointestinal blood loss).

Hypertension

Chronic LBP

Irritable Bowel Syndrome

previous history of depression

LABS/TESTS:

WBC- 6 k/u

RBC 2.95 ml/ul

hemoglobin- 8.7 g/dl

hematocrit- 26.3%

Segmented neutrophils 68%

Lymphocytes- 14%

Eosinophils 7%

Sodium 135 mmol/l

Chloride 99mmol/l

Glucose 157 mg/dL

BUN- 24 mg/dl

Albumin- 3.2 g/dl

Uric Acid- 10.2

Magnesium - 1.6mg/dl

ASSESSMENTS:

c/o SOB with exertion

Stated "Pain 8/10" after peak time for pain medication administered.

Consumed outside food that family brought for her.

Requested more food from Nutrition dept. after breakfast was served and consumed.

T- 97.9

Bp 120/64

RR -14 regular

P-74, 2+, regular

Capillary refil

Diet: Consistent Carbohydrate- 15/24 hr period

[lwandel]

Her O2 sat was 95% while resting. I was unable to get Resp. Ther. to come check it when she was going to the bathroom. Her c/o SOB was after ambulating to and from the bathroom. Once she got back in bed, she would say "phew, i can hardly breath", or "I need to catch my breath". Once she even had to use her inhaler. But i have no objective data to support impaired gas exchange, which is why i'm not going to use that dx right now.

Since pain is the main priority, I want to go with that, but I'm not sure which nsg dx would best fit her needs.

Should I just go with Acute Pain r/t osteomyelitis?

[Esme12, ASN, BSN, RN]

What did she say hurt? If it was her toe, foot, leg then yes....osteo.

[Esme12, ASN, BSN, RN]

Hi May, there was no complaint of chest pain, only dyspnea with exertion. Her pain stems from her low back and osteomyelitis. She does have risk factors for heart disease, but my instructor seem to want us to focus on psychosocial and "at risk for _____ r/t medication" at this point in our clinicals. But, since i also have an exam on tuesday, this care plan may not meet all of her standards. I think the pain issue is more relevant than the risk for electrolyte imbalance. so I will probably go with that one.

I do appreciate your comments :)

Thanks,

Leslie

I think you are on track....

So I would go

Pain

Activity as this also poses a safety risk pain Rx/unsteady gait

Nutrition

Risk for electrolyte diuretics she is also at risk for glucose imbalance

[nurseprnRN, BSN, RN]

See what happens when I go away for a few days? :)

Good work! :flwrhrts:

And did you tell your faculty about the NANDA-I 2012-2014? Enquiring minds wanna know.

[Esme12, ASN, BSN, RN]

I think we have a good one here!