Brandi Anastacio, Concept Map: Care Plan, March 28, 2014, N360 Prof.

Rosado Nursing Dx Ineffective Health Maintenance Desired Outcomes Before Discharge Patient demonstrates positive health maintenance behaviors as evidenced by keeping scheduled appointments, making diet and exercise changes, improving home environment, and following treatment regimen. Patient demonstrates use of adaptive techniques that promote ambulation and transferring. Interventions Assist the client in problem solving personal barriers in making positive health maintenance changes and address them. Educate client on the importance of keeping appointments, making diet/exercise changes and improving blood glucose control. Arrange for a consult with physical and occupational therapy after clients scheduled right BKA surgery. Assist client in creating a diet plan and arrange for a dietician consult. Involve family members in creating plans for care at home. Physical therapy consult regarding ambulation and transferring pre and post op. Occupational therapy consult regarding ADLs pre and post op. Perform ROM to all extremities and bear weight as tolerated daily. Assist client in using IS and CDB post op. Assess all body systems for complications related to impaired physical mobility, especially post op. Educate client on the importance of integrating new techniques in maintaining mobility and address any concerns with accepting new limitations. Assist client in creating a PT/OT plan for home with family support. Assess for baseline and changes in heart rate, blood pressure, peripheral pulses, respirations, integumentary and urinary output at least every four hours. Assess for chest pain. Administer medication as prescribed, noting response and watching for side effects and toxicity. Clarify with physician parameters for withholding medications. Maintain adequate ventilation and perfusion, as in the following: Place patient in semi- to highFowler's position, place patient in supine position, administer oxygen therapy as prescribed. Administer stool softeners as needed. Educate client on the need to report changes, i.e. SOB, chest pain, dizziness, confusion, anxiety. Assess periphery: pulses, color, temp, movement, cap refill, skin impairment and pain. Monitor O2Sat, heart rate, Hgb/Hct levels: decreased levels=decreased amount of oxygen delivery. Administer medications as prescribed to treat underlying problem. Note -response: Anti-platelets, Peripheral, Vasodilators, Anti-hypertensive, Inotropes Discuss examples of lifestyle factors that can promote improved tissue perfusion (avoiding crossed legs at the knee when sitting, changing positions at frequent intervals, rising slowly from supine/sitting to standing position, avoiding smoking, reducing risk factors for atherosclerosis [obesity, hypertension, dyslipidemia, inactivity]). Instruct the patient to inform the nurse immediately if symptoms of decreased tissue perfusion persist, increase, or return. 1

Impaired Physical Mobility

Decreased Cardiac Output

Patient has adequate cardiac output as evidenced by systolic BP within 20 mm Hg of baseline; urine output greater than or equal to 30 mL/hr; strong peripheral pulses; warm, dry skin; eupnea with absence of pulmonary crackles.

Ineffective Tissue Perfusion: Peripheral

Patient maintains optimal peripheral tissue perfusion as evidenced by strong palpable peripheral pulses, reduction in or absence of pain, warm and dry extremities, adequate capillary refill (less than 2 seconds).

Brandi Anastacio, Concept Map: Care Plan, March 28, 2014, N360 Prof. Rosado Impaired Tissue Integrity Infection Patient's tissues return to an as optimal as possible state in structure and function, while preventing further damage and infection. Patient is free of infection, as evidenced by normal vital signs, labs and absence of local signs of infection like purulent drainage, redness, warmth and pain from wound and surrounding areas.
Assess condition of tissue, characteristics of the wound, including color, size, drainage, and odor. Assess for elevated body temperature and patient's level of discomfort. Provide skin care as ordered/needed: premedicate & maintain sterile technique. Encourage nutritional intake to promote wound healing. Administer antibiotics and other medications as ordered. Monitor white blood cell (WBC) count. Monitor for the following signs of infection: Redness, swelling; increased pain; purulent drainage from incisions, injury, and exit sites of tubes, drains, or catheters. Any suspicious drainage should be cultured. Elevated temperature. Color of respiratory secretions. Appearance of urine. Maintain or teach asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access management. Administer and teach use of antimicrobial (antibiotic) drugs as ordered. Wash hands and teach other caregivers to wash hands before contact with patients and between procedures with the patient. Assess pain characteristics. Assess the patient's expectations for pain relief. Assess the patient's willingness or ability to explore a range of techniques aimed at controlling pain. Respond immediately to complaint of pain. Determine the appropriate pain relief method: Pharmacological or Non-pharmacological: deep breath, distraction, re-positioning Assess patient's level of anxiety. Determine how the patient uses defense mechanisms to cope with anxiety. Maintain a calm manner while interacting with the patient. Establish a working relationship with the patient through continuity of care. Encourage the patient to talk about anxious feelings and examine anxiety-provoking situation: impending BKA. Assist patient in assessing the situation realistically and recognizing factors leading to the anxious feelings. Avoid false reassurances. Support the patient's use of coping strategies that the patient has found effective in the past. Assist the patient in developing new anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). Remind the patient that anxiety at a mild level can encourage growth and development and is important in mobilizing changes.

Acute Pain

Patient reports satisfactory pain control at a level less than 3 to 4 on a 0 to 10 rating scale.

Anxiety

Patient maintains a desired level of role function and problem solving.

Brandi Anastacio, Concept Map: Care Plan, March 28, 2014, N360 Prof. Rosado Evaluations: Ineffective Health Maintenance goal partially met, due to the fact that I was not able to care for the patient post op, but did institute interventions preop. Client verbalized the importance of maintaining appointments after discharge and improving her glucose control, through diet, exercise and insulin administration. Her niece was at bedside and stated the desire to assist the client in reaching her health care goals for improvement. Client stated, I do not want to lose my left leg also! Impaired physical mobility goal also partially met as client appropriately used assistive devices like a front wheel walker and wheelchair. Client stood with assist and sat in a chair during mealtimes. Client did display some shortness of breath on exertion, but it was relieved by rest. Client stated I know it will be hard when my leg is gone, but with PT and my family, I can still get around. Decreased cardiac output goal met by assessing for physical signs and symptoms of decreased CO and administration of medications. Clients vital signs were, heart rate 67 bpm, resp-22, BP-130/76 and O2Sat 97%. Client has a pacemaker with ICD, felt on palpation. Client denied chest pain. There were no crackles heard on auscultation in lung fields and client experienced minimal SOB only during ambulation. Ineffective Tissue Perfusion (Peripheral) goal only partially met due to clients medical diagnosis of peripheral arterial disease in the lower extremities. Peripheral pulses were strong in upper extremities, but weak in lower, requiring a Doppler for assessment. Skin within normal limits in upper extremities, but lower extremities were cool, shiny, and hairless with two necrotic wounds on the right foot. Monitored labs showed a decrease in Hgb & Hct, but clients O2Sat remained >92%. Impaired Tissue Integrity goal partially met. A focus wound assessment was performed on the right foot, two necrotic areas, one on the big toe and one on the lateral surface of the foot. The borders were unequal and the surrounding tissues appeared dry. Wound care performed with topical silver sulfadiazine and dry gauze. Clients temperature remained below 37.0C and pain controlled based on clients expectations. Client has a planned BKA. Otherwise, no noted skin impairment on any other body surfaces. Infection goal met with a focus on assessment and administration of antibiotics. The wound was cultured prior to my care and results are pending. Client was placed under contact isolation and given broad spectrum antibiotics for treatment. Client did not experience any fever during my care and hand hygiene was performed regularly. Teaching was also provided to client and her family regarding the importance of hand washing, especially when caring for any open wounds. Client stated I always make sure I wash my hands, especially after the bathroom and before eating, but I will make sure to wash even more now. Acute Pain goal met. Client stated pain only felt on palpation of right lower extremity and upon multiple blood draws, due to difficult access. Client also stated that a pain level of 3-4 out of 10 is tolerable for her and that she manages it well without medications. Client instructed on deep breathing, distraction and repositioning. Client stated It really helps when I move around and sometimes for short periods, I can dangle on the side of the bed. PICC inserted to alleviate painful blood draws. Anxiety goal met. Established a therapeutic and trusting relationship with the client. Discussed with client her concerns regarding surgery. Client stated that talking usually helps her to relieve anxiety and also being surrounded by friends and family. Client interacted with family and niece took pictures of client standing and walking around the room. Client stated I am saying goodbye to my leg and taking pictures to remember how I looked when walking, things will be different, but I can do it with my familys support. 3

Brandi Anastacio, Concept Map: Care Plan, March 28, 2014, N360 Prof. Rosado Discharge Plan Client will be discharged to a rehab facility that will focus on mobility changes associated with her right BKA. Client and health care provider have included clients sister and niece on treatment plan and they have agreed to assist in supporting the client through this transition. They all live within the same household. Client and family will require teaching regarding wound care and how to assist client with her mobility (Physical/Occupational therapist should be consulted regarding this). Client will require max assistance in ADLs, especially during the immediate post-op period in regards to bathroom use, ambulation and transferring. Client has begun using a walker and wheelchair, but will also learn to incorporate other devices like a slide board, crutches/cane, shower chair, hospital bed and trapeze. Client will need consultation with social services, physical therapy, occupational therapy and home care services. Follow up appointments will need to be made with her primary care provider, cardiologist, endocrinologist, and surgical doctors. In regards to patient education, client and family prefer to learn through demonstration and performance. Barriers to learning are mainly emotional, due to grief and anxiety of lost limb and new challenges. Topics to teach include: Wound care, signs and symptoms of infection and how to prevent it, mobility changes and use of assistive devices, when to notify the provider of complications, nutrition (diabetes/wound healing), medication administration and compliance, safety, diabetic precautions (limb care, s/s hypo-hyperglycemia, vision care, skin care). Teaching will need to begin now and repeated through admission. Follow up teachings should also be given during rehab and home visits by PT/OT/Home Care.

Brandi Anastacio, Concept Map: Care Plan, March 28, 2014, N360 Prof. Rosado

Resources

Gulanick, M., & Myers, J. (2011). Nursing care plans: diagnoses interventions, and outcomes. (7th ed ed.). PA: Mosby. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., et al, L., & Camera, I. M. C. (2011). Medical-surgical nursing, assessment and management of clinical problems. (8th ed. ed.). St. Louis, Missouri: Mosby