Please help with my first care plan

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Hi everyone! I am currently working on my first care plan and need a little bit of help. I went to the hospital tonight and picked out my patient for my clinical day tomorrow. He is in the hospital for an abdominal trauma received from swallowing razor blades. I have completed the nursing diagnosis portion but am having trouble with creating a pathophysiology tree. We did not receive any help or direction on what the teacher is looking for, and I can't find any information in my textbook or online. I am thinking of writing "Abdominal Trauma" at the top of the page and then making a sort of flow chart explaining how the trauma could impact the different aspects of his health (lab values, problems w/ mobility, infection, etc.). Is anyone familiar with these pathophys trees and am I completely off track? Thanks in advance for all fo your help.

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Specializes in Cardiac, Derm, OB.

Patho is about the reason behind the injury. Is this a psych patient? suicide attempt? What type of trauma resulted? (ruptured bowel?) Need background to give idea of which way to go.

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The pateint is on a Neuro floor and has bipolar disorder. Would this be the main focus of the patho tree and the abdominal trauma be the result? Yes, it was a suicide attempt (his 4th in 2 months).

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Oh, and the razor blades were removed through exploratory surgery. I couldn't find anything in the chart to suggest that the blades did specific damage, although the pt is now NPO.

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Specializes in Cardiac, Derm, OB.

patho would be on bipolar disorder. start with brief general definition/description of disorder. next include characteristics/most common s/s of bipolar. (include suicide attempts) then "my patient" exhibited __________ symptoms. (include suicide attempts). also, list most common treatments/therapies. list which ones patient has been treated with. include the surgery r/t abdominal trauma 2ndary to bipolar episode and attempt to commit suicide.

make sure to cite your references. usual good places, tabers dictionary (often incl. definition and patho) and your medsurg book.

hope this gives you and idea and place to start.

i have attached a very basic patho example. this example does not include the "patient exhibited" yet. hope it helps.

DEHYDRATION 2.doc

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Thank you! That is really helpful to me and a great point in the right direction.

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Specializes in Cardiac, Derm, OB.

Just uploaded an example in above link. It is a basic so it has no patient exhibited info yet.

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Thank you very much! I really appreciate your help!

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Specializes in Cardiac, Derm, OB.

Your welcome.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i don't know how you could have come up with nursing diagnoses (nursing problems) for this patient if you had not already examined thoroughly what was going on with him. i always advise students to follow the nursing process when care planning. care planning is determining the patient's nursing problems and doing something about them. the nursing process is the problem solving method that we use to do that. the first step, assessment, includes doing the following activities before any diagnosing, the second step, is done:

before seeing and working with your patient you had an opportunity to review information in his chart which would have contributed a great deal of information. first that this was a suicide attempt by a bipolar individual who was most likely in a depressed phase. he is now a post-op patient who has had abdominal surgery and there are a lot of things that need to be monitored in someone who has undergone general anesthesia. there are also special considerations for someone who has made a suicide attempt. the pathophysiology of tissue damage by trauma or disease and how the body responds to it can be found in any book of pathophysiology and should have been part of your assessment activity (see http://www.merck.com/mmpe/sec21/ch307/ch307a.html). this information will be needed for some of the related factors of your nursing diagnostic statements which is why it needs to be known before you begin doing your diagnosing.

see this thread for more information and examples on the construction of a care plan: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

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