I am really struggling on how to write a care plan for a non-compliant patient. I'm not sure non-compliant is the exact word, maybe non-involved would be better, but for lack of a better term, I'll use non-compliant...
Let me preface this by saying I work as a student extern, and have been working in my current role for 18 months now... I understand not all patients will be compliant. It seems we have been taught how to write care plans for patients that ARE compliant, so I am really struggling with my care plan. I have spent hours pouring over posts trying to find help, but I am still not sure of myself...
SITUATION: patient admitted with "abdominal pain/ileus". She had N/V for 3 days prior to going to ER. Pain is sharp, intermittent, and located from hypogastric/suprapubic area to epigastric region. Pain was 9/10 without medication, 2/10 with pain medication. Pain was not alleviated by anything but narcotic pain medication, and there seemed to be no aggravating factors. The day I had the patient, she had been there for 4 days. An NG tube was placed just 12 hours before I started working with her (after she had been there 3 days).
At the time of admission, the patient was suspected to have an ileus vs SBO. Over the course of the next couple days, the hospitalist and GI doctor both went back and forth about whether it was ileus or SBO - even after 2 KUB's and an MRI. Then, the CT comes back showing dilated CBD (my guess is the CBD was damaged during the cholecystectomy, though I don't know the date of the cholecystectomy). The morning I was there, the surgeon orders laxatives, soap suds enema, and limited ice chips.
NG was on LIWS, draining significant amounts of greenish brown fluid (750mL in 8 hours). Patient was in a lot of pain, and requesting pain medication before it was due (I was not passing meds for this patient on this day). Patient had not had a BM or flatus the first 3 days of admission, but had a smear the 3rd night. Bowel sounds were hypoactive. Vitals all normal, LFT's showed acute spike on 2nd day of hospitalization, but had been decreasing since. Patient complained of nausea regularly, and was unable to take zofran, so she was taking phenergan regularly and was pretty sedated.
Patient has a history of cholecystectomy, depression, osteoarthritis, fibromyalgia, non-insulin dependent DM, hernia pain and hypothyroid. Patient had history of narcotic use for chronic pain, and the doctor said to limit narcotics, but the patient requested the narcotics before they were due because of the pain.
The patient had a very flat affect, and did not want to be bothered. She refused care, and just wanted to be left alone. She complained to the charge nurse that she had been bothered too much. The only time she wanted to be bothered was to receive her medications (which the RN was doing, so I followed on her coat-tails every chance I got, and so the patient couldn't complain about being bothered more than necessary).
I administered the enema, and the patient got up to the bathroom, and had very little success, but promptly requested more pain medication and went back to bed.
So for my care plan I have to come up with 6 diagnosis. Here is what I have:
- Acute pain related to dysfunctional gastrointestinal motility
- Constipation related to decreased gastrointestinal motility
- Nausea related to irritation in the gastrointestinal system
- Deficient knowledge related to promoting gastrointestinal motility
- Deficient fluid volume related to inadequate fluid volume intake
- Imbalanced nutrition: less than body requirements related to nausea and vomiting
(NOTE: we are only required for this assignment to write the diagnosis and r/t info.)
Then I have choose 2 of those to come up with goals, and interventions with rationale. I have to list at least 3 objective and 3 subjective data points and come up with a nursing intervention for each data point, along with rationale.
For this patient, I believe the acute pain is priority. For this assignment, I am selecting Acute Pain and Deficient Knowledge to write goals, subjective/objective data, interventions and rationale.
So here is my problem...because the patient wouldn't talk to me much, and was refusing care, I can't figure it out!
As far as acute pain, I know I am going to have subjective and objective data, but the patient wasn't interested in doing anything, so how can there be goals if the patient doesn't want any? Her only goal was to not have pain, and she wanted nothing to do with getting up and walking to promote GI motility, but that's what my instructor wanted me to do. She refused a bath, even though the NG vent had leaked all over her arm. I finally got a bath done and sheets changed when we did the enema, but otherwise, she would have been happy to stay like that.
Let me add that I had a 19 hour surgery myself which is why I am becoming a nurse, so I do understand the importance of pain control, and wanting to be left alone, so that's not the issue...my issue is how to make goals and come up with interventions
for a patient who simply wants to be given pain meds and left alone to rest.
Thank you in advance for your help!