I need help with my care plan!

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    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
    Goal: 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.
    Goal: 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!
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    1) imbalanced nutrition:less than body requirements r/t inability to ingest food(lack of appetite) aeb weight loss
    goal: 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.
    goal is not measurable or time specific. outcome is not reasonable. in how many days should a 1 pound weight gain happen? i really don't know, but you should state something. i do know that it takes 3500 calories to = a pound. that would be in addition to the daily calorie intake required to sustain the person's current weight.

    how is "medicate for pain nausea and manage side effects" treating the patient for the weight loss? that makes no sense. determine if one reason why he is losing weight is because is daily calorie intake is too low and then boost it up. give him foods he likes. send him 6 meals a day instead of 3.
    should i also list abdominal cramping/pain, nausea, diarrhea, increased flatulence in my r/t factors? is lack of appetite considered inability to ingest?
    related factors are the etiology, or underlying cause, of the problem (nursing diagnosis). imbalanced nutrition: less than body requirements is the intake of nutrients insufficient to meet metabolic needs. diarrhea and flatulence do not cause a reduced intake of food. abdominal pain is specifically listed as a defining characteristic (symptom) for this diagnosis so it is not a related factor either. nausea you can use. lack of appetite sounds the same as a lack of interest in food and an aversion to eating which are both defining characteristics (symptoms) for this diagnosis so it cannot be a related factor either.

    better: imbalanced nutrition: less than body requirements r/t nausea aeb weight loss of 10# without effort recently, lack of appetite, hypogastric region pain, "crampy feeling" in lower abdomen for the past 2 wks, increased gas and diarrhea
    2) risk for falls r/t history of falls, over age 65, diarrhea and fatigue.
    goal: 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.
    this patient has orthostatic hypotension (b/p drops when he stands up) and that is a risk factor for falls as well.

    better: risk for falls r/t orthostatic hypotension, history of falls, over age 65, diarrhea and fatigue.
    i would add:
    • risk for deficient fluid volume r/t gi bleeding
  5. 0
    Thanks so much! That makes total sense!
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    After pondering this....it really doesn't make sense to me. In this manual, the related factors for imbalanced nutrition:less than body requirements are:
    Inability to ingest/digest food; inability to absorb nutrients
    Biological/psychological/economic factors
    (Increased metabolic demands,such as burns)
    (Lack of information/misinformation/misconceptions)
    So, which one would nausea into or come under?
  7. 0
    the nausea is specifically why the patient is unable to eat (inability to ingest food). when people are nauseated they don't eat because they don't want to end up vomiting. can you remember a time when you were nauseated. did you want to eat anything? if you did what happened? rather than say imbalanced nutrition: less than body requirements r/t inability to ingest food you want to be as specific as you can, so it is perfectly acceptable to say imbalanced nutrition: less than body requirements r/t nausea because it describes exactly why (remember this is the etiology part of the diagnostic statement) the person hasn't been taking in any food. the next part of the statement (the aebs) goes on to tell what the result of that is--weight loss.


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