I am a nursing student and supposed to write a care plan for a case scenerio using the Nursing Diagnosis Manual by Doenges, Moorhouse & Murr. We are supposed to include the goal and the outcome criteria. I am wondering if my nursing diagnosis, goal statement outcome criteria and interventions look alright?
Here is case: 66 yr. old man admitted to ER, admitting diagnosis is Gastrointestinal Bleeding Rule out Colon Cancer. Weight is 165 lbs.,BP-100/58, lack of appetite ,wt. loss of 10# without effort recently, diarrhea, fatigue, increased gas, pain described as "crampy feeling" in lower abdomen-hypogastric region the past 2 wks, some nausea, states he passed out when getting up from breakfast table and must have fallen and hit head because he has large bruise under his left eye.
Here are my nursing diagnosis,goal statement and outcome criteria, and interventions:
1) Imbalanced nutrition:less than body requirements r/t inability to ingest food(lack of appetite) AEB weight loss
: Nutrition meets metabolic demands Outcome
: Client will demonstrate that nutrition meets metabolic demands AEB weight gain of 1 or more pounds during hospitilization. Interventions
: 1)Obtain weights using same scale, same time of day, and same clothing, as much as possible. 2) Medicate for pain nausea and manage side effects.
Should I also list abdominal cramping/pain, nausea, diarrhea, increased flatulence in my r/t factors? Is lack of appetite considered inability to ingest?
2) Risk for falls r/t history of falls, over age 65, diarrhea and fatigue
: Remain free from falls Outcome
:Client will demonstrate lifestyle changes to reduce risk factors and protect self from injury AEB no report of falls during hospitilization Interventions
: 1)Assess mood, coping abilities, personality styles 2) Provide/instruct in use of mobility devices and safety devices, like grab bars and call light/personal assistance systems.
Should I just leave the r/t as hx of falls and not have the age, diarrhea and fatigue listed , although they are listed as contributing factoris in the manual. Also, if he only had the one fall, is that considered to be "hx of falls"? Sorry for all the questions.
Thanks for any help anyone is willing to give me........FAST!