Care plan help

You must follow the steps of the nursing process in the sequence that they occur in writing a care plan. You cannot determine any nursing diagnoses until you have a list of all your patient's symptoms. All nursing diagnoses are based upon the symptoms that your patient has. Every nursing diagnosis has a set of signs and symptoms and your patient must have at least one or more of them in order for you to apply that nursing diagnosis to the patient's situation. So, having this list of your patient's symptoms is very, very important to the writing of your care plan.

The steps of the nursing process are:

1. Assessment (collect data from medical record, do a physical assessment of the patient, look up information about your patient's medical diseases/conditions)
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 diagnosis 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)

You can find explanations on how to write a care plan on these two threads:

• http://allnurses.com/forums/f8/desparately-need-help-care-plan-279187.html
• http://allnurses.com/forums/f205/help-nursing-care-plans-277791.html

N/G tubes tend to cause irritation of the mucus membranes of the nose and throat causing excess mucus production and sore throat. Did your patient have any of that? The patient was NPO. How are nutritional needs being (or not being) met. Is D51/2NS with KCL in it providing enough nutrition for the patient? Attachment 5949. How is the patient getting their ADLs (bathing, dressing, transferring from bed or chair, walking, eating, toileting and grooming) accomplished? Do they need any assistance with them? If so, then there are self-care deficits to be addressed. These are all things that need to be assessed in STEP #1 of the nursing process before moving on to picking nursing diagnoses.

The only symptoms you have listed are abdominal distension and diarrhea. However, with a small bowel obstruction I am sure there are more that you either haven't posted or have overlooked. Did the doctor's notes indicate why the bowel obstruction was occurring? Does this patient have abdominal pain? Were there bowel sounds? Did you look up information about small bowel obstructions? Quite often these patients tend to lose fluid because it becomes trapped in the bowel and since peristalsis is either slowed or shut down, the fluid just sits in the bowel or is lost through diarrhea. It would be interesting to see what a set of this patient's electrolytes looks like. So, knowing that pathophysiology, you have a potential nursing diagnosis of:

• (Risk for) Deficient Fluid Volume secondary to small bowel obstruction R/T fluid loss through bowel AEB distended abdomen and diarrhea

I can't help you if you can't tell me what her symptoms are. All you are telling me about is her medical diagnoses. That information only provides you with the pathophysiology. Did you read the two threads I referred you to? A symptom is an objective observation that you made or a subjective perception made by the patient--NOT medical diagnoses and conditions.

If this patient had an abdominal surgery with a wound dehis, then she has an incision. What does the incision look like? An incision is a symptom because it is not normal to have an incision. Does it have any drainage? Describe it. There is a nursing diagnosis for it.

STEP #2 - Determination of the patient's problem(s)/Nursing diagnosis

list of abnormal assessment data:

• abdomen distended
• complains of pain over entire abdomen 7 on 1-10 scale
• NG to LCS draining dark green fluid
• complains of nausea without vomiting
• Expelling large amounts of dark brown liquid BM
• surgical incision mid-abdominal area intact with staples present
• lower portion of incision has half-dollar size opening approx 1 1/2 in deep pink around edges draining moderate amount of serous fluid
• left of abdominal incision is a quarter size opening approx 1/2 inch deep pink around edges draining small amt of serous drainage
• foley draining amber urine
• anxious

match abnormal assessment data to likely nursing diagnoses (prioritized by Maslow's):

• Impaired Tissue Integrity R/T surgical intervention AEB 1 1/2 inch and 1/2 inch diameter open mid-abdominal incision areas with serous drainage
• Nausea R/T abdominal distension AEB patient reports of nausea without vomiting [other symptoms of nausea are that could be reported here are gagging, increased salivation, increased swallowing, and sour taste in mouth]
• Diarrhea R/T surgical bowel shortening AEB more than 3 loose liquid stools per day
• Acute Pain R/T surgical intervention AEB complaints of abdominal pain of 7 on a 1 to 10 scale
• Anxiety R/T [situational crisis?] AEB [no symptoms listed] see the NANDA information on the related factors and defining characteristics (symptoms) for this diagnosis at this website: Anxiety

STEP #3 - Planning

write measurable goals/outcomes and nursing interventions:

You will do this for each symptom listed with each nursing diagnosis. For example, for the first diagnosis:

• Impaired Tissue Integrity R/T surgical intervention AEB 1 1/2 inch and 1/2 inch diameter open mid-abdominal incision areas with serous drainage
  • Long-term goal: Upon discharge the patient will understand the plan of care to treat the surgical wound.
  • Short-term goal: Surgical wound will remain free of any infection.
  • Nursing Interventions:
    • Sterile dressing changes will be made twice a day
    • The size, depth, presence of drainage and erythema and any odor will be noted at time of dressing change once daily and documented.
    • Monitor skin around wound for reaction to tape used to hold dressings in place
    • Teach the patient why the dressing change is being done as a sterile procedure
    • Teach the patient what wound care may be expected to be done upon discharge
    • The foley catheter will be maintained to prevent incontinence and prevent the wounds from becoming moist with urine.

Assuming you gave me most of the symptoms this patient has, there is enough information there for you to complete this care plan. You merely need to do the goals and interventions for each of the remaining nursing diagnoses. You, however, need to think back about the signs and symptoms this patient displayed with regard to anxiety because you haven't listed any.

Just follow the steps of the nursing process. The major step is getting the assessment data. That is most important. It takes a long time and a lot of experience to get good at collecting assessment data. That is why I also suggest students look up the signs and symptoms of their patient's medical diagnoses because often you missed something that was right in front of you. That's OK. You are learning, but that is how you learn to correct yourself. Here is a thread that tells you what you need to review in the medical record as well when looking for assessment clues: http://allnurses.com/forums/2228927-post5.html. Don't be so quick to start choosing nursing diagnoses until you have all your assessment data and you can make a list of symptoms. Got it now?

What I didn't say is that you really should use some sort of nursing diagnosis reference in choosing nursing diagnoses. Each nursing diagnosis has a set of symptoms (NANDA calls them defining characteristics) just like every medical diagnosis has a set of symptoms. Your patient must have one or more of those symptoms in order for you to classify the patient as having that particular nursing diagnosis.