Care plan Dx

[smansur]

Need help coming up with the best Nursing Diagnosis that fits best with my pt.

47 yo male admitted for vomitting blood, hx alcohol abuse, only spanish speaking, lives out of his car, no steady job, no relations with his family after they kicked him out.

3 days later: He pulled out his catheter because he didn't know what it was (lack of communication probably due to the language barrier), has bleeding after voiding (due to catheter removal) and has extrememly low platelet count.

I first thought Risk of Injury r/t confusion and disorientation aeb waking up and self removing catheter. also thought about Imbalanced Nutrition-

Need help figuring out what suits best! Thanks!

[SarahAne]

I'd say something related to the nutrition aspect, ranks higher according to Maslows, and it's a more immediate need. But I'm still a student too, but that's probably what I'd do. interested to see what others have to say.

[smansur]

Thanks, me too!

[Constantly Surprised]

One of the nursing DX listed from NANDA is Impaired Verbal Communication with an objective defining characteristic as 'Inability to speak dominant language' I'd say that's a fit here. Discusses an intervention as 'determine primary language and cultural factors.' As well as 'Obtain translator or provide written translation or picture chart' as another intervention.

So, Impaired verbal communication related to language/cultural barriers as evidenced by lack of understanding English medical interventions?

I'm just a student myself, but that one sort of stands out for me as the best one (Only because you can't really proceed with anything else until you have a way to communicate)

[smansur]

Touche

Thanks

[xtxrn, ASN, RN]

Low platelets will kill him in about 40 minutes (tops) if the varices he probably has bulging in his esophagus blow. Have esophageal varices been ruled out? If not, see what you have for risk for bleeding to death (I'm sure it's worded much more pleasantly).

Airway sounds ok, breathing sounds ok, circulation could tank if he blows.

You only need one?

This guy is a treasure trove :) Risk for injury, risk for DTs (also a huge injury factor- and bleeding since a wonk on the head could cause a head bleed much more easily, as alcoholics have cerebral atrophy and more room for blood to collect before it shows up), altered mental status (also r/t possible DTs, and nutritional status.... ) Do you have an ammonia level on this guy?

Let me know how many nursing diagnoses you need to have.... :)

[Esme12, ASN, BSN, RN]

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems. why? because as a working rn you will be using that method many times a day at work to resolve all kinds of issues and minor riddles that will present themselves. that is what you are going to be paid to do. most of the time you will do this critical thinking process in your head. for a care plan you have to commit your thinking process to paper.

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

[nurseprnRN, BSN, RN]

yeah, i was thinking he yanked out his foley maybe because he doesn't know why he has one, but maybe also because his nh3 (ammonia) and bilirubin levels are high and he wouldn't remember anyway... we know this because he has an alcohol history (bad liver), is vomiting blood (esophageal varices until somebody proves it to me otherwise (bad liver) though i will entertain the idea of gastritis), and i'll bet he has big hard belly with ascites (bad liver), dark urine (bad liver), and yellow sclerae (did i mention.... bad liver?).