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Discussion

Care Plan feedback

working on my first care plan and thought I'd throw it out there to get any feedback on improvements needed, items lacking, clarification etc., etc.,

Pt. is 89yr old female admitted for dehydration, Hx of cervical cancer (receiving radiation therapy), HTN, Neutropenic.

Prioritized Nursing Diagnosis:

1. Deficient fluid volume related to active fluid loss and inadequate fluid intake, as evidenced by persistent diarrhea and inability to drink sufficient liquid volume secondary to fatigue.

2.Risk for infection related to decreased white blood cell count secondary to radiation therapy as evidenced by laboratory data of wbc=1.4.

3. Risk for impaired skin integrity related to persistent diarrhea as evidenced by redness and moisture in perineal area.

still working on getting the goals and interventions for the #1 diagnosis.

Any thoughts?

tia

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  • Experts

deficient fluid volume related to active fluid loss and inadequate fluid intake, as evidenced by persistent diarrhea and inability to drink sufficient liquid volume secondary to fatigue.

if the patient is not drinking fluids "secondary to fatigue" then it seems to me that the patient has another problem:
fatigue
. fatigue is
not
a defining characteristic of
deficient fluid volume
and might seem like an etiology. i think it is stretching things a lot. if this patient has that much diarrhea, use the diagnosis of
diarrhea.
your evidence needs to be more specific. how much volume isn't the patient taking in (this can be obtained from i&o records). if diarrhea is a problem the number of stools per day should have been monitored. if diarrhea is a problem the patient should be having other symptoms of it: abdominal cramps, pain, hyperactive bowel sounds.

risk for infection related to decreased white blood cell count secondary to radiation therapy as evidenced by laboratory data of wbc=1.4.

"risk for" diagnoses refer to problems you feel have a good likelihood to happen because the patient has the risk factors. since the patient is getting radiation therapy their immune system is compromised and an infection can take hold. there is no evidence of infection because there is no infection yet. laboratory data of wbc=1.4 is not evidence of any
problem
. this statement will be ok as
risk for infection related to decreased white blood cell count
.

risk for impaired skin integrity related to persistent diarrhea as evidenced by redness and moisture in perineal area.

if this patient already has redness of the skin, that is impaired skin (erythema) and probably a fungal infection. it is more correctly diagnosed as
impaired skin integrity r/t moisture aeb reddened perineal area.

still working on getting the goals and interventions for the #1 diagnosis. any thoughts?

interventions are aimed at doing something about the cause (etiology) of the problem, if possible, or trying to ease or eradicate the symptoms of the problem (the evidence, aeb items). goals are always what you expect and predict will happen as a result of your interventions. they are usually going to be an improvement or stabilization of the problem, it's etiology or the symptoms (the evidence, aeb items). everything is related to the evidence that supports the nursing problem.

  • Author

Thanks for the feedback, your pointers totally make sense and help me in critical thinking about each of these statements.

I appreciate it!

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