Nursing Care Plan


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Medical Diagnoses:Ineffective coping related to diabetes and amputation, anxiety, disturbed body image and acute pain


1.   1. Ineffective coping related to diabetes and amputationn.

·         Decreased use of social supports

·         Poor concentration

·         Verbalization of inability to cope

·         Destructive behavior toward self (smoking)

·         Inability to meet role expectations

2. Anxiety related to deficient knowledge of diabetes and current condition.

·         Shutting out staff

·         Frustration

·         Fatigue

·         Isolation

·         Smoking

3. Deficient Knowledge related to current condition and diabetes.

·         Wearing boots that are not made for diabetics

·         Commitments on not knowing what is going on with him and condition

4. Disturbed body image related to the amputation of his right toes.

·         Verbalizing the disturbance about the amputations

·         Inability to cope

·         Pt. seems anxious and guarded

Chief Complaint: A 44 year old white male with an hx. of diabetic foot ulcers had inflamed and swollen right fourth toe amputated and has developed cellulitis from right ankle up 6 inches on shin.

 

Priority Assessment:  Monitor vitals and pain.  Practice standard precautions to help prevent infection. Monitor LOC and mobility. Monitor the bandages and appearance of incision site and spread of cellulitis.  Monitor I’s and O’s. Monitor hematology and blood cultures. Monitor glucose levels and give insulin as scheduled.

5. Acute pain related to amputation.

·         Pt. rates pain an 6 out of 10 on pain scale before PO pain meds are given

·         Physician prescribes Morphine IV 2mg Q2H and Percocet  10mg Q4H

·         Pain increases during ambulation, repositioning and dressing change

6. Delayed Surgical recovery related to diabetes

·         Hx of diabetic foot ulcers and neuropathy

·         Pt. has developed cellulitis

·         Noncompliance with wearing protectant boot

8. Risk for infection related to amputation

·         Hx of MRSA

·         Physician prescribes Zyvox to treat and prevent infection

·         1 inch incision where rt 4th toe was amputated and 4 inch incision from previous injury

7. Impaired walking related to amputation of right toes

·         3 right toes amputated on right foot

·         Protectant boot must be worn during ambulation


NANDA Diagnostic Statement: Ineffective coping related to diabetes and amputation AEB blaming medical staffing for his current condition.

Behavioral Outcome / Goal: Pt. will address any questions and/or concerns when nurse is in the room for any reason by 3/16/20xx.  Pt. will encourage family to address any questions and/or concerns. Pt. will participation in the viewing and discussion of wound site by 3/16/20xx.


Nursing Interventions:

 

1.       Assist the pt. to identify & explore specific situations that are creating stress & possible alternatives for dealing with the situation by allowing at least 1 hour per shift for interviewing and teaching.

2.      Maintain consistency in approach and teaching whenever interacting with the pt.

 

3.      Encourage participation in care by assisting the pt. to maintain activities of daily living to degree possible.

 

4.      Encourage support from the family by allowing participation in care, encouraging questions, and allowing expression of feelings.

 

5.      Assist the pt. to identify and use available support systems before discharge from hospital._____________________

Rationale:

 

1.      Identification of problem area is the first step in problem solving and promotes creative problem solving. (Cox’s Clinical pg:773)

 

2.      Reduces stress.  Promotes a trusting relationship. (Cox’s Clinical pg:773)

3.      Promotes self-care, enhances coping, builds self-esteem, and increases motivation and compliance. (Cox’s Clinical pg:773)

4.      Broadens support network. Builds self-esteem in support systems. (Cox’s Clinical pg:773)

5.      Broadens the support network to reach short-term and long-term goals. (Cox’s Clinical pg:774)______________________________

Client Response:

 

1.      When changing the pt.’s dressing the nurse addressed any questions or concerns that the pt. might have and also educated in that time.

2.      Every time that the nurse was in the pt.’s room she allowed the pt. to voice any questions or concerns.

3.      Pt. prefers dressing changes more frequently during a day to view site and discuss the progression. Also pt. can ambulate as much as he chooses as long as he wears the protectant boot.

4.      Pt.’s family was involved with dressing changes. They viewed the site and the nurse explained the reasoning for how it was dressed and the progression of the site and also discussed their and the pt’s concerns.

5.      Pt. understands the role of the nurse is to educate and pt. feels more comfortable with addressing any questions and concerns that he and/or family may have.___________________________

Summarize impressions of client progress toward outcomes / problem resolution: Pt. is stable. Pt. is experiencing pain of 6 out of 10 on pain scale. Physician prescribed Morphine IV 2mg Q2H and Percocet 10mg Q4H.  Pt. has 1 inch incision on rt. Foot where 4th toe was removed covered with 2 4x4’s soaked in Dankins Solution wrapped in Kerlix gauze bandage. Also, 4 inch incision on medial right foot from a previous injury, healing well. Cellulitis developed on ankle up pt.’s shin 6 inches, skin is hot, inflamed and blanching. Pt. is voiding on own. Ambulating on own with a protectant boot on right foot. Physician ordered pt. NPO for diet. BM early on 3/16/12 lose stool.  The previous night pt. was abusive to night nurse and pt. seems very anxious and frustrated.  During a dressing change the pt. expressed his frustrations and concerns with the treatment that is being done and after the nurse explained what was going on with the pt. concerning the cellulitis and the diabetes, the pt. began to calm down and open up with questions and concerns as did the family.   Discharge needs to include foot care for diabetes. Resources for diabetic needs such as socks and shoes.  Proper management of diabetes. Lifestyle changes that can have a positive affect with controlling diabetes. Support groups that deal with self-imagery issues (amputees). Social services that can provide for financial assistances maintaining medical needs. Initiate referral to psychiatric clinical nurse to intervene in significant

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