Care plan help

  1. Here is my scenario: A 15 year old female is admitted for nausea, vomiting and diarrhea x 3 days. She is pale, with sunken eyes, and dry lips and mucous membranes.

    We have to do two nursing Dx, I already have Fluid Volume Deficient. Some people in my class are saying nausea as the second nursing Dx.... but if it is that what are the r/t's? This is all the information provided by the teacher for this care plan.

    Thanks in advance!
  2. Visit jescalynn profile page

    About jescalynn, ASN

    Joined: Mar '12; Posts: 77; Likes: 36
    Registered Nurse; from US
    Specialty: 1 year(s) of experience in Developmentally delayed


  3. by   jescalynn
    Wait am I looking too deep into this, would the second just be risk for deficient fluid volume?
  4. by   MendedHeart
    risk for ??Electrolyte imbalance
  5. by   Esme12
    Quote from jescalynn
    Wait am I looking too deep into this, would the second just be risk for deficient fluid volume?
    That was cute........ but if this patient is
    is pale, with sunken eyes, and dry lips and mucous membranes.
    is that a risk?

    What happens with dehydration? What happens to the electrolytes with dehydration. diarrhea, vomiting?
  6. by   morte
    what, besides fluid, is she NOT getting enough of?
  7. by   MendedHeart
    Imbalanced Nutrition
  8. by   nurseprnRN
    My NANDA-I 2012-2014 has twenty-seven possible related factors for the nursing diagnosis of Nausea. Page 476. Get it now. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

    You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

    There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

    "Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)

    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.
  9. by   jescalynn
    Thank you everyone! Im a first semester student and this is my first time doing careplans so I am finding it a bit overwhelming I know Ill get the hang of it eventually
  10. by   nurseprnRN
    Get the book. Really. You can thank me later.