ok.....now looking at your data.....What do we know?
patient with c-diff. He was admitted to the hospital w/the medical diagnosis of dehydration, fall, syncope, & syncopal episode. He also has a history of great toe & little toe amputation on his right foot. I have to come up with 5 different key problems & nursing diagnosis. While taking care of him, I did notice that he had diarrhea, is on normal saline 1000 mL, infusing at 75 mL/hr. Iv looked great & all. So far, what I have come up with is 1)key problem of amputation w/a nursing diagnosis of impaired physical mobility; 2)key problem pain w/nursing diagnosis of pain, acute; 3)key diagnosis of c-diff w/a nursing diagnosis of risk of dehydration r/t infectious diseases, & 4) (which doesn't really fit to me) key diagnosis confusion w/a nursing diagnosis of injury, risk for.
Now remember, FIRST.... what is YOUR assessment of the patient....not the patients medical diagnosis. What are their vital signs...What co-morbidities (other diseases) do the have? How do they other disease processes affect this patient now? hat is your assessment? Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.
Care plans are the recipe card for the patients care....what do you need to do now to help that patient be well. ....You NEED to have a care plan book....which one do you have? As I stated before I use....Ackley: Nursing Diagnosis Handbook, 9th Edition and...Gulanick: Nursing Care Plans, 7th Edition. It is also important to have a NANDA I reference....Nanda list as contributed by vickirn (assistant administrator) nursing diagnoses 2012 - 2014.pdf
Now tell me about your patient...what are they complaining of...What do they NEED....
If your patient was admitted with diarrhea and Syncope/Syncopal episode/Fall. Can diarrhea cause Syncope? What is dehydration? What are the signs of dehydration? What would be reflected in the vital signs of a dehydrated patient? Can being dehydrated cause you to pass out?
Your pateints pressing problem is that the patient has C-diff
....What exactly is C-diff.....CDC - Clostridium difficile Infection - HAI
. What are the complications or C-diff? http://www.mayoclinic.com/health/c-difficile/DS00736
So C-diff causes diarrhea...
NANDA I describes diarrhea
as....the Passage of loose, unformed stools with t
Abdominal pain; at least three loose liquid stools per day; cramping; hyperactive bowel sounds; urgency....
Related Factors (r/t)
: Anxiety; high stress levels
: Adverse effects of medications; alcohol abuse; contaminants; travel; laxative abuse; radiation; toxins; tube feedings
Infectious processes; inflammation; irritation; malabsorption; protozoal, gastrointestinal disorders
Therefore....your patient has a key diagnosis of Diarrhea
R/T (related to) C-diff infection AEB (as evidenced by) passage of loose, unformed, foul smelling stools.
What else is important to your patient....that they got so dizzy that they passed out and fell. Can someone become so dehydrated that they pass out? What is dehydration
? A lack of fluid in the body.
Your patient has Deficient Fluid volume .....
NANDA I defines deficient volume
as....Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level.....which has
Defining Characteristics as.
.....Changes in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness.....
caused by/Related Factors (r/t)
Active fluid volume loss; failure of regulatory mechanisms
The patient has deficient fluid volume R/T diarrhea caused by C-diff (infectious agent) AEB syncope and .....what evidence do you have...what is the urine output what are the vital signs...what is your assessment.
You choose Impaired physical Mobility
.......why do they have impaired physical mobility? How would being dizzy/syncopal have to do with their ability to move about safely? What does NANDA I say about impaired physical mobility....
A limitation in independent, purposeful physical movement of the body or of one or more extremities
Decreased reaction time; difficulty turning
; engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on pre-illness disability/activity); exertional dyspnea; gait changes
; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability
; slowed movement; uncoordinated movements
Related Factors (r/t)
; altered cellular metabolism; anxiety; body mass index above 75th age-appropriate percentile; cognitive impairment
; contractures; cultural beliefs regarding age-appropriate activity; deconditioning; decreased endurance; depressive mood state; decreased muscle control
; decreased muscle mass; decreased muscle strength
; deficient knowledge regarding value of physical activity; developmental delay; discomfort; disuse; joint stiffness; lack of environmental supports (e.g., physical or social); limited cardiovascular endurance
; loss of integrity of bone structures; malnutrition
; medications; musculoskeletal impairment; neuromuscular impairment; pain; prescribed movement restrictions; reluctance to initiate movement; sedentary lifestyle; sensoriperceptual impairments......Which of these fit your patient?
According to your assessment....What do you need to address next? pain? Confusion? Is this patients confusion acute or chronic?
Do you see where this is going? I was able to get all this information from what you provided, which wasn't a complete assessment/information. Which is what a care plan is supposed to do.....What do you think is next?