Desperatly need care plan help

  1. i have a care plan due soon and since my instructor is not emailing me back and answering my questions, i could really use some help. my patient is 78 years old and diagnosed with gallstone pancreatitis. he is in a lot of pain, has inspiriatory and expiratory wheezes throughout his lungs, sob, his bun (42) and creatinine (4.25) levels are also really high which to me indicates acute renal failure. the patient is on 3lnc, xopenex aerosol treatments, dilaudid q4hrs, lasix, potassium chloride, zosyn, has elevated bilirubin, wbc, alt, ast, amylase, and lipase.he is on a clear liquid diet, is hr ranges from 99-110, occasional sinus tachy on telemetry, +1 edema lower extremities, productive cough with thick yellow sputum, firm &distended/obese abdomen, voided 400ml during 7 hours of clinical day, took in a little over 1000ml during that time, and had warm/dry skin. potassium, iron, albumin, sodium, calcium, hct, hgb, and rbc are all low. there is obviously a lot going on with this patient so i am having a hard time coming up with 5 diagnoses, 3 of which i have to work out. so far i have
    • ineffective airway clearance related to increased mucous production as evidenced by sob, inspiratory and expiratory wheezes throughout lungs, pox 93% on 3lnc, productive cough with thick yellow sputum and xopenex aerosol treatments three times a day.
    • acute pain related to obstruction and inflammation of the common bile duct, inflammation, edema, distention of the pancreas, and peritoneal irritation as evidenced by patient reporting a pain of 8 on a 1 to 10 scale, the need for dilaudid every 4 hours, pain and tenderness in ruq and back, and pain when coughing.
    • excessive fluid volume related to renal insufficiency as evidenced by intake greater than output, shortness of breath, and +1 edema bilaterally in lower extremities.
    i'm not sure if the second one sounds right because i tried describing what causes the pain, and in this case it's the gallstones (obstructing the common bile duct) and the pancreatitis. i also wasn't sure if i should include the diagnsostic studies (ultrasound:[font=rockwell]small stones and sludge within the gallbladder. gallbladder wall approx. 4mm, and ct scan: [font=rockwell]gallstones, dilated cbd and peri-pancreatic inflammation)

    i was also thinking of using ineffective breathing pattern due to the pain and inflammation and maybe also due to the use of dilaudid which causes respiratory depression, and maybe the secretions could be a cause too???

    and for the last one i was going to do imbalanced nutrition: less than body requirement related to reduced food intake (clear liquid diet), and increased metabolic needs...

    i would really appreciate any feedback, it's really nice to bounce my ideas off other people.
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    About schantzy143

    Joined: Feb '11; Posts: 9; Likes: 1


  3. by   Trilldayz,RN BSN
    I have a couple questions: Is he weak? Bedbound? What was his temperature? Are you allowed to have psychosocial nursing diagnoses? Does he have family that comes?

    Here are some ideas: Risk for injury, impaired physical mobility, Risk for loneliness, Fatigue,Risk for impaired skin integrity (due to lack of mobility if bed bound)
  4. by   all4ofus
    I had a 34 year old woman with her second episode of pancreatitis triggered by binge drinking. I used acute pain, of course, but also nausea, because she couldn't hold anything down. Then imbalanced nutrition due to the nausea, vomiting, and NPO orders; noncompliance due to the fact that she had been advised that she needs to quit drinking altogether but continued to binge a few times a week. And lastly, risk for infection. The pancreas is basically in the process of autodigesting itself, so abscesses and secondary infections are likely. I hope this helps, and good luck!
  5. by   justchill
    My instructors always tell me when in doubt and there is an issue with airway, go with airway