Please help! Im stuck!

  1. Hello,
    I am a new nursing student on my first clincal rotation. Im trying to write my second care plan and having such a hard time. My first flowed so smoothly but I am having a real hard time finding a main NANDA to do for this patient. She is 87 and lives an ECF. I have a list of many NANDAS for some of her previous med. history (Schiz, Pyshocosis, HTN, CAD, COPD), but our instructor wants us to focus on why she is here this time and about her new diagnosis-colorectal cancer. She came in with a lg bowel obstruction and had a resection. She now has a colostomy, PEG (which they said there using for drainage??) and a central line where she was recieving TPN. I wasnt allowed to discuss her new diagnosis with her because my instructor didnt know how much she had been told yet. (also, with her mental state I dont think it would have mattered) I feel like maybe I should focus on nutrition-She had nausea, vomiting and didnt eat or drink for days before. Then they put her on the TPN for a few days, now shes on full liquid with supplement shakes and is barely drinking that stuff. She has only a few teeth with very dry mouth and difficulty swallowing. For some reason when I work it up though it just doesnt sound to me like her BIGGEST issue. Anyway this is what I have so far but Im just not happy with it...Any suggestions on something better???

    Imbalanced nutrition: Less than body requirements
    R/T nausea and vomiting secondary to bowel obstruction
    AEB pt states impaired taste sensation, lack of appetite, inadequate caloric intake, abdominal pain and cramping,discontinuation of TPN 7/22, full liquid diet, weight loss of 10# in one month, impaired dentition, difficulty swallowing
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    About ColeRobert

    Joined: Aug '09; Posts: 2


  3. by   nlion87
    If she is a post op Pt how about risk for ineffective airway clearance r/t immobility. Did she exhibit pain?? If so, on what scale form 0 to 10 Also, what about knowledge defecit r/t her condition or risk for impaired skin integrity (is there abdominal incision with dressing, did you witness stool draining?? presence of tubes, drains??). In addition, most colostomy pt's may exhibit disturbed body image r/t new ostomy or stoma but given your comments about her exhibiting signs of dementia this last one may be stretching it a bit in this instance as would knowledge deficit unless you could tailor these last to diagnosis to perhaps her primary caregiver (i.e. family member husband etc) if one exists.
  4. by   nlion87
    Also, if given she just had surgery and immobile there is risk for DVT
  5. by   Daytonite
    hi, colerobert. something struck me right off when i first started reading your post. you said, "our instructor wants us to focus on why she is here this time and about her new diagnosis-colorectal cancer." and i wondered why you would think of doing something other than that. so, before i help you sort all this nursing diagnosis business out we need to talk a little about what a care plan is. your instructor is correct.

    a care plan is a listing of a patient's nursing problems and what you are going to do about them. the nursing problems are given names we call nursing diagnoses. what you do for the nursing problems are called nursing interventions. goals or outcomes are, hopefully, the result of the nursing interventions. when you write all this stuff down on a piece of paper to memorialize it, we call your efforts a care plan. most often, however, we are thinking through this care for our patients in our minds at so rapid a pace that a lot of the individual actions that lead us to the final conclusion go by our conscious mind un-noticed. when we first have to sit down and commit our thinking process about this to paper is when it is most difficult. we have a tool to help us do the thinking and organizing. it is called the nursing process. it is a rather handy thing.

    the nursing process is a problem solving method. by the time you finish nursing school you should know how to use it and what goes on in each of its 5 steps. you will be tested about it on your nclex licensing exam. the nursing process was derived from the scientific process that is used in many of the sciences. it is called critical thinking and helps us to rationalize answers. whenever there is a problem or question, following the steps of the nursing process will help you arrive at a solution in a logical way. the idea is to avoid guessing at answers and solutions.

    the 5 steps of the nursing process can be remembered by the mnemonic adpie:
    • assessment
    • diagnosis
    • planning
    • implementation
    • evaluation
    a care plan is like taking a snapshot (a kodak moment) of a patient and doing an adpie on them. it makes no logical sense to determine and solve their nursing problems from yesterday or last week, does it? the patient is here and present in front of you now. help and assistance is needed now. and that is what your instructor was trying to tell you when they said "focus on why she is here this time and about her new diagnosis-colorectal cancer". past history can be considered, but there is new stuff going on that needs to be addressed. so, let me show you how care planning is really done using the nursing process. all the writers of care plan books use the nursing process to write those care plans.

    step 1 assessment - the entire problem solving process is based on data that you have collected about the patient. assessment consists of:
    • a health history (review of systems) - 87 year old female admitted from an ecf with a large bowel obstruction. she hadn't eaten or had anything to drink for several days and been nauseated and vomiting. she was taken to surgery where she had a colon resection and colostomy for colorectal cancer. she has cad, htn, copd and a history of schizophrenia and psychosis.
    • performing a physical exam - a post operative patient needs to be assessed for many different things. the surgically incision should have been checked. iv sites need to be checked. the abdomen needs to be assessed--bowel sounds, distension, pain. except for your mention of abdominal pain and cramping there was no mention of bowel sounds or anything about the status of the incision or the colostomy. an incision needs to be checked for size, drainage and description, amount, and any odor. the assessment of pain includes noting:
      • where the pain is located
      • how long it lasts
      • how often it occurs
      • a description of it (sharp, dull, stabbing, aching, burning, throbbing)

        • have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
      • what triggers the pain
      • what relieves the pain
      • observe their physical responses
        • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
        • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
        • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
    you have a great deal of assessment data on the patient's eating and mouth. with cad, hypertension and copd i would expect there to be heart and respiratory symptoms of some kind. what were her lung sounds? was her heart rate regular or irregular? has she had any problem with chest pain? cad is the forerunner of chest pain and heart attacks. postop patients are monitored for the effects of general anesthesia and immobility:
      • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
      • hypotension (shock, hemorrhage)
      • thrombophlebitis in the lower extremity
      • elevated or depressed temperature
      • any number of problems with the incision/wound (dehiscence, evisceration, infection)
      • fluid and electrolyte imbalances
      • urinary retention
      • constipation
      • surgical pain
      • nausea/vomiting (paralytic ileus)
    having a peg, central line and colostomy require assessment, nursing care and monitoring and yet nothing about them is mentioned in what you posted. what does the skin around the peg and central line look like? is there any redness, swelling or pain (symptoms of inflammation)? what does the colostomy stoma look like?
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - i say about nurses, adls-r-us. we assist patients in accomplishing their activities of daily living. ecfs where this patient came from are experts at it. her transfer papers from the ecf would have had information about what adl assistance she needed there. so, what does this patient need help with more so now that she has had this devastating medical diagnosis of cancer and now has a colostomy? there are 4 self-care deficit nursing diagnoses. is she able to dress herself? bathe herself? walk by herself? eat by herself? is she incontinent of bladder? does she get up and go to the bathroom to pee by herself? what did you do for this person when you were her nurse?
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - a student should always look up the medical disease/condition, its signs and symptoms and complications in order to double check that they didn't miss seeing and noting one of them in the patient. you also need to know and understand why the doctors are ordering the things that they are. that is how you learn. you can't wait until you get the lecture on colon cancer or colostomies in class:
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - you mention nothing about the medications this patient is getting. antibiotics? anything for surgical pain? for the heart and lung conditions? anything for the schizophrenia? what about the side effects of the medications she is getting? i was particularly wondering when i saw she had a very dry mouth and difficulty swallowing. i was thinking that the dry mouth was a side effect of medications and the difficulty swallowing was due to a sore throat as a result of being intubated during general anesthesia. intubation is the presence of a foreign body, results in the evoking of the inflammatory response (redness, heat, swelling and pain) and often a very irritated and sore throat. did she also have an n/g tube for a while, another foreign body? is it possible that this is what is going on? [pathophysiology of the inflammatory response: Histamine effect]
    step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - from all the data you have collected we are most interested in the abnormal assessment data. the abnormal stuff is actually the signs and symptoms (also called cues) of the nursing problems which we are going to find and give names (called nursing diagnoses) to. i can only work with what you actually posted and this is the abnormal data i was able to isolate from your post:
    • weight loss of 10# in one month
    • inadequate caloric intake
    • barely drinking supplement
    • only has a few teeth
    • very dry mouth
    • impaired taste sensation
    • difficulty swallowing
    • abdominal pain and cramping
    • central line and peg tube
    • colostomy
    step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - every nanda nursing diagnosis has a list of defining characteristics (signs and symptoms). what you have to do is match your abnormal assessment data to the nursing diagnoses that will apply to this patient. it helps to have a nursing diagnosis reference of some sort. the appendix of taber's cyclopedic medical dictionary has this. if you don't have a nursing diagnosis reference book or your own copy of taber's, these two websites contain between them about 80 of the most commonly used nursing diagnoses and the nanda information about them:
    based on the abnormal data just above, these are the nursing diagnoses that would apply prioritized according to maslow's hierarchy of needs. however, because of overlooked data there are important nursing diagnoses that have been missed. you need to go back over your information and re-think your assessment data.
    • imbalanced nutrition: less than body requirements r/t inability and decreased ability to ingest food aeb weight loss of 10# in one month, inadequate caloric intake [this needs to be more specific. . .do you have calorie counts?], barely drinking supplement [again this needs to be more specific. . .you need the amounts she is consuming], impaired taste sensation, and difficulty swallowing.
    • impaired dentition r/t ??? aeb missing teeth (only has a few teeth)
    • acute pain r/t surgical intervention aeb abdominal pain and cramping [needs more specific pain assessment]
    • risk for infection r/t invasive procedures
    step #3 planning (write measurable goals/outcomes and nursing interventions) - now write you goals and interventions for each nursing diagnosis based on the aeb items.

    - - - - - - - - - - - - - - -

    your diagnostic statement: imbalanced nutririon: less than body requirements r/t nausea and vomiting secondary to bowel obstruction aeb pt states impaired taste sensation, lack of appetite, inadequate caloric intake, abdominal pain and cramping, discontinuation of tpn 7/22, full liquid diet, weight loss of 10# in one month, impaired dentition, difficulty swallowing.
    the construction of the 3-part diagnostic statement follows this format: [font=arial unicode ms]

    p (problem) - e (etiology) - s (symptoms)

    • problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
    • etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
    • symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
    lets break your diagnostic statement down into its component parts and remember that your instructor said "focus on why she is here this time and about her new diagnosis-colorectal cancer"
    • problem: imbalanced nutririon: less than body requirements
      • definition: intake of nutrients insufficient to meet metabolic needs
    • etiology: nausea and vomiting secondary to bowel obstruction
      • this might have been true prior to admission, but since the surgery, bowel resection and the colostomy, that is not the reason for the imbalanced nutrition anymore. as of the day you took care of her, she had a shortened colon (they took out __ inches of the large intestine). the large intestine is mainly involved in conserving water for the body. when the gi tract gets backed up anywhere, yes, there will be nausea and vomiting. but surgery cleared this stoppage. there is no more bowel obstruction. a colostomy was done and food can now pass through the gi tract without impediment. at this point in time, the reason the patient doesn't take in enough nutrients is because she just isn't able to eat enough. you have to figure out why.
    • symptoms: pt states impaired taste sensation, lack of appetite, inadequate caloric intake, abdominal pain and cramping, discontinuation of tpn 7/22, full liquid diet, weight loss of 10# in one month, impaired dentition, difficulty swallowing.
      • this has to be the evidence of the problem. so, objective and subjective data is always ok. however, things like discontinuation of tpn 7/22 and full liquid diet are treatments that were ordered by the physician. they do not count as evidence of any nursing problem--ever. they are not responses by the patient to the problem of an intake of nutrients insufficient to meet metabolic needs. in addition a lack of appetite is pretty vague and can and should be more specific in description. impaired dentition doesn't tell us how it affects the nutrition either. as you saw above, there is a nursing diagnosis that better accommodates that symptom--at least the way you wrote it. does that make sense? and, to me, that would have fallen under a self-care deficit because she probably doesn't do good, or any, mouth care (that's a bathing/hygiene self-care deficit). a care plan is sometimes all about how you write the words.
    hope this has helped you out. please re-think your assessment data. there are several nursing diagnoses that could be used here, but couldn't because you didn't have the assessment data to support them. i'm sure the data was there, but that you accidentally overlooked it. skill in assessement comes with time and experience. this is why you must look up these surgeries and information about the diseases when you are a student. you will often miss something.

    if you still have questions, ask. you can also see other examples of care planning and diagnosing on this thread: - help with care plans
  6. by   gninab
    Check your nursing diagnoses related to fluids and electrolytes for this patient.
    Last edit by gninab on Aug 1, '09 : Reason: Another poster's response contained the same information I was providing and much more.