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Are these careplans ok?

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by srg4784 srg4784 (Member)

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I have a pt. last week has increased WBC's, decreased RBC, Hgb, Hct. I wrote down all the pathological things that can cause this and in every column I have malnutrition and for the WBC's infection of course. The pt. is very weak in both legs and when eating the pt. vommits. Also has a surgical wound a colostomy closure. Here's what I've come up with:

Imbalanced nutrition: less than body requirments r/t intake less than needed secondary to fear of vommiting AMB client statement, "If I eat I will throw up" .........also this is evidenced by labs, can I put that too?

Risk for infection r/t surgical wound

Activity Intolerance r/t generalized weakness AMB dyspnea on exertion.

TIA:idea:

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RosesrReder has 13 years experience as a ADN, BSN, RN.

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I think it's good.........but where is your as evidenced by?

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Danish is a MSN, APRN, NP and specializes in vascular surgery.

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Looks good. I would probably use risk for falls instead of activity intolerance due to the the risk for injury...just my opinion. :)

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Daytonite has 40 years experience as a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

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when you are writing a care plan you perform an assessment of the patient first. after gleaning as much information as you can get from the patient's medical record and doing your own interview and physical assessment of the patient, you make a list of all the abnormal items. based on what you've posted, this is what i come up with:

  • surgical procedure: closure of colostomy
  • dyspnea on exertion
  • vomits when eating
  • has a surgical wound
  • weak in both legs
  • increased wbc's
  • decreased rbc
  • decreased hgb and hct

from that list, you develop your nursing diagnoses.

the very first thing that caught my eye was that this is a surgical patient, is that right? that automatically sets me thinking about the complications that can occur to someone following surgery when they have had a general anesthetic and surgery on the bowel. (check out this thread: https://allnurses.com/forums/f205/appy-195227.html#post1969425.)

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

i'm thinking that the patient's nausea is more likely due to a possible mild paralytic ileus and/or side effect of anesthetic agents that were used. some anesthetic agents will cause immediate nausea the minute food hits the belly. the minute the surgeon's scalpel and hand touch any part of the patient's bowel, peristalsis shuts down. it takes days for it to re-boot and start up. that's why the assessment of bowel sounds in postop abdominal surgery is crucial. even so, it often can take up to six weeks or more before peristalsis returns to normal. during that time, nausea can come upon the person when they eat. nausea is a symptom of a sluggish bowel or paralytic ileus.

elevated wbcs are seen in inflammations, infections, leukemic neoplasia, trauma, stress, and tissue necrosis. decreased rbcs are seen in hemorrhage, hemolysis, anemia, advanced cancer, leukemia, patient's receiving chemotherapy, chronic illnesses, renal failure, overhydration, multiple myeloma, pernicious anemia, rheumatoid disease, subacute endocarditis, and dietary deficiency. decreased hemoglobin is seen in anemia, severe or chronic hemorrhage, cancer, nutritional deficiencies, lymphoma, systemic lupus erythematosis, sarcoidosis, kidney disease, splenomegaly, and sickle cell anemia. decreased hematocrit is seen in anemia, hyperthyroidism, cirrhosis, hemorrhage, dietary deficiency, rheumatoid arthritis, multiple myeloma, malnutrition, leukemia and hemoglobinopathy. my resource on this is mosby's diagnostic and laboratory test reference, 4th edition, by kathleen deska pagana and timothy james pagana, 1999. surgery is a form of trauma and stress. blood and fluids are lost during surgery. fluids, in particular are lost, when the patient is on the surgical table with an open abdomen as they are evaporated and lost into the atmosphere. it is typical for doctors to order blood counts after surgery to check rbc, wbc hbg and hct levels to see if there is any possible internal hemorrhage going on. it's also possible that there was more blood lost in surgery than expected. the ebl (estimated blood loss) during surgery can be found on the operative record, the anesthesia record or the nurses intraoperative notes if the doctor didn't include it in the progress note that be wrote. without documentation in the patient's chart of malnutrition which is a medical diagnosis, it would be inappropriate to address signs and symptoms of it if they do not exist.

i couldn't even begin to guess why the patient has weakness in both legs, but it is an adl (mobility) that can be addressed with nursing interventions. the weakness could be due to the effects of anesthesia, just lying in bed for awhile, being out of physical condition especially if the patient is older, or may have another condition such as arthritis or other musculoskeletal medical condition. i would be concerned about the high potential for the development of thrombophlebitis because of just having surgery and not being able to move around too much. having had surgery and some low blood counts makes me concerned that anemia may be an underlying cause of both the dyspnea and the patient's weakness with regard to mobility.

why, i'm asking myself, would this patient have dyspnea on exertion when the only medical condition you have listed is that there was a surgical closure of a colostomy? i have to think that something else is missing from this patient's data assessment. dyspnea on exertion is not a normal thing. there is usually some underlying medical condition at the root of it, such as obesity, anemia, and any number of heart and lung conditions. if you look at the definition of the nursing diagnosis, activity intolerance, it states, "insufficient physiological or psychological energy to endure or complete required or desired daily activities". so, this means that the patient is either not psychologically able to move or there is physiological evidence (elevated heart rate, ekg changes, dyspnea) to support such etiologies for this (immobility, sedentary lifestyle, imbalance between oxygen supply and demand and overall general weakness which would apply to not only the legs but the entire body). since you haven't mentioned any of these, i'm going to work from the premise that this is a postop patient who is most likely suffering some fatigue as a result of blood loss anemia.

this patient had surgery. does the patient have any pain? you didn't mention any, but it would seem reasonable since their belly was opened up that they are receiving some kind of pain medication although you haven't mentioned it.

i think a better list of nursing diagnostic statements would be the following:

  1. nausea r/t postsurgical anesthesia and surgical manipulation of the intestinal organs amb vomiting upon eating
  2. impaired tissue integrity r/t surgical intervention amb [description of the surgical wound]
  3. acute pain r/t surgical intervention amb [physical description of patient's pain]
  4. fatigue r/t anemia amb dyspnea on exertion, weakness in both legs, decreased rbcs, and decreased hbg/hct.
  5. risk for infection r/t surgical intervention and altered mobility[your interventions for this would be to monitor for signs and symptoms of a wound infection or thrombophlebitis and perform things to prevent the development of those conditions]

just my thoughts on this, based upon what you posted.

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123 Posts; 3,192 Profile Views

when you are writing a care plan you perform an assessment of the patient first. after gleaning as much information as you can get from the patient's medical record and doing your own interview and physical assessment of the patient, you make a list of all the abnormal items. based on what you've posted, this is what i come up with:

  • surgical procedure: closure of colostomy
  • dyspnea on exertion
  • vomits when eating
  • has a surgical wound
  • weak in both legs
  • increased wbc's
  • decreased rbc
  • decreased hgb and hct

from that list, you develop your nursing diagnoses.

the very first thing that caught my eye was that this is a surgical patient, is that right? that automatically sets me thinking about the complications that can occur to someone following surgery when they have had a general anesthetic and surgery on the bowel. (check out this thread: https://allnurses.com/forums/f205/appy-195227.html#post1969425.)

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

i'm thinking that the patient's nausea is more likely due to a possible mild paralytic ileus and/or side effect of anesthetic agents that were used. some anesthetic agents will cause immediate nausea the minute food hits the belly. the minute the surgeon's scalpel and hand touch any part of the patient's bowel, peristalsis shuts down. it takes days for it to re-boot and start up. that's why the assessment of bowel sounds in postop abdominal surgery is crucial. even so, it often can take up to six weeks or more before peristalsis returns to normal. during that time, nausea can come upon the person when they eat. nausea is a symptom of a sluggish bowel or paralytic ileus.

elevated wbcs are seen in inflammations, infections, leukemic neoplasia, trauma, stress, and tissue necrosis. decreased rbcs are seen in hemorrhage, hemolysis, anemia, advanced cancer, leukemia, patient's receiving chemotherapy, chronic illnesses, renal failure, overhydration, multiple myeloma, pernicious anemia, rheumatoid disease, subacute endocarditis, and dietary deficiency. decreased hemoglobin is seen in anemia, severe or chronic hemorrhage, cancer, nutritional deficiencies, lymphoma, systemic lupus erythematosis, sarcoidosis, kidney disease, splenomegaly, and sickle cell anemia. decreased hematocrit is seen in anemia, hyperthyroidism, cirrhosis, hemorrhage, dietary deficiency, rheumatoid arthritis, multiple myeloma, malnutrition, leukemia and hemoglobinopathy. my resource on this is mosby's diagnostic and laboratory test reference, 4th edition, by kathleen deska pagana and timothy james pagana, 1999. surgery is a form of trauma and stress. blood and fluids are lost during surgery. fluids, in particular are lost, when the patient is on the surgical table with an open abdomen as they are evaporated and lost into the atmosphere. it is typical for doctors to order blood counts after surgery to check rbc, wbc hbg and hct levels to see if there is any possible internal hemorrhage going on. it's also possible that there was more blood lost in surgery than expected. the ebl (estimated blood loss) during surgery can be found on the operative record, the anesthesia record or the nurses intraoperative notes if the doctor didn't include it in the progress note that be wrote. without documentation in the patient's chart of malnutrition which is a medical diagnosis, it would be inappropriate to address signs and symptoms of it if they do not exist.

i couldn't even begin to guess why the patient has weakness in both legs, but it is an adl (mobility) that can be addressed with nursing interventions. the weakness could be due to the effects of anesthesia, just lying in bed for awhile, being out of physical condition especially if the patient is older, or may have another condition such as arthritis or other musculoskeletal medical condition. i would be concerned about the high potential for the development of thrombophlebitis because of just having surgery and not being able to move around too much. having had surgery and some low blood counts makes me concerned that anemia may be an underlying cause of both the dyspnea and the patient's weakness with regard to mobility.

why, i'm asking myself, would this patient have dyspnea on exertion when the only medical condition you have listed is that there was a surgical closure of a colostomy? i have to think that something else is missing from this patient's data assessment. dyspnea on exertion is not a normal thing. there is usually some underlying medical condition at the root of it, such as obesity, anemia, and any number of heart and lung conditions. if you look at the definition of the nursing diagnosis, activity intolerance, it states, "insufficient physiological or psychological energy to endure or complete required or desired daily activities". so, this means that the patient is either not psychologically able to move or there is physiological evidence (elevated heart rate, ekg changes, dyspnea) to support such etiologies for this (immobility, sedentary lifestyle, imbalance between oxygen supply and demand and overall general weakness which would apply to not only the legs but the entire body). since you haven't mentioned any of these, i'm going to work from the premise that this is a postop patient who is most likely suffering some fatigue as a result of blood loss anemia.

this patient had surgery. does the patient have any pain? you didn't mention any, but it would seem reasonable since their belly was opened up that they are receiving some kind of pain medication although you haven't mentioned it.

i think a better list of nursing diagnostic statements would be the following:

  1. nausea r/t postsurgical anesthesia and surgical manipulation of the intestinal organs amb vomiting upon eating
  2. impaired tissue integrity r/t surgical intervention amb [description of the surgical wound]
  3. acute pain r/t surgical intervention amb [physical description of patient's pain]
  4. fatigue r/t anemia amb dyspnea on exertion, weakness in both legs, decreased rbcs, and decreased hbg/hct.
  5. risk for infection r/t surgical intervention and altered mobility[your interventions for this would be to monitor for signs and symptoms of a wound infection or thrombophlebitis and perform things to prevent the development of those conditions]

just my thoughts on this, based upon what you posted.

thank ya ma'am....your always a huge help. one day i will master these nursing diagnosis.....i will!!!:monkeydance:

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