Care plan help with nursing DX questions!! =)

Published

so i'm writing my first care plan by myself and i'm having a bit of trouble coming up with a nursing diagnosis. We gather all the information on the patient but we don't actually get to assess them ourselves until tomorrow, but i need to have something to show my instructor tomorrow.

My pt is a 79 year old male with alizheimer's, seizure disorder, hypothyroidism. he presented in ER with rectal bleeding. his Medical DX is obstructing inflammatory process in left colon. He had a surgery scheduled for tomorrow but it has now been cancelled and he has an oncologist consult instead. There are also polyps present stating they may be lymphoma. He is on antiboitoics so i can't use risk for infection. his S/S that i got from his chart are diarrhea with urgency, poor skin turgor, diverticulosis, lymphoma, submucosal lesions, hemorrhois, reflux, thyroid dsyfunction and seizures. Any suggestions? Any help would be so very much appreciated!!

PS-I was thinking risk for injury due to the fact that he is an older gentleman with Alzheimer's and seizures, but he does have full ROM and isn't at risk for falls according to the scale. His wife also assists him. Thanks guys!!!

Up Vote Up Vote ×
Specializes in GERIATRICS, DEMENTIA CARE, MED-SURG.

how about self care deficit

Up Vote Up Vote ×

you could do acute pain, confusion, risk for constipation..

Up Vote Up Vote ×

I'm not sure if he actually has problems in that area. I know that his wife is there to help him at all times, but he may be able to do all those things. I only went in and introduced myself to him today so i didn't really get a chance to see what all he can do by himself.

I also forgot to mention that his I&O is 1350/500. is that within normal ranges??

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

nursing diagnoses are always based upon the symptoms that the patient has because it is the symptoms that are the evidence of the problems. in the case of having never actually seen the patient you need to work with the symptoms you get from the written information or can extrapolate from the medical diagnoses (all medical diagnoses are also based upon symptoms that are evidence of their existence).

his medical diagnoses/conditions are:

  • obstructing inflammatory process in left colon + polyps which may be lymphoma
  • alzheimer's disease
  • seizure disorder
  • hypothyroidism
  • diverticulosis
  • hemorrhoids
  • diarrhea with urgency

you need to look up the signs and symptoms of these conditions. the inflammatory response is something that you will see so commonly in patients that you should know the 4 cardinal signs of inflammation at the drop of a hat: redness, heat, swelling and pain. it is harder to see all 4 of these signs when they are occurring internally, but they are there. it is the swelling that often causes pain. alzheimer's disease does not cause seizures. you can look up information about these conditions on the websites listed on this thread: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html. i would suggest using the merck manual, webmd or medicine net sites.

there is information on care planning on

there is a nursing diagnosis of diarrhea which you can use for his problem of diarrhea with urgency. here is a link to a web page about it: diarrhea. break the other medical conditions down into their symptoms to see what possible nursing diagnoses might apply. if this patient is likely to have surgery or chemotherapy then teaching is necessary. what diagnosis would cover that do you think? if he is bleeding and has become anemic he has lost fluid; what diagnosis would apply to that do you think?

Up Vote Up Vote ×

ok, can i use diarrhea as my nursing dx? Diarrhea related to inflammation as evidenced by urgency and hyperactive bowel sounds??

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.
ok, can i use diarrhea as my nursing dx? Diarrhea related to inflammation as evidenced by urgency and hyperactive bowel sounds??

It's probably because of the diverticulosis which may or may not be inflammed. How about Diarrhea related to increased intestinal motility as evidenced by urgency and hyperactive bowel sounds?

Up Vote Up Vote ×

sounds lots better than mine! =)

Another one that i came up with was risk for imbalanced fluid volume related to intake in excess of output. Does that one work? I thought about it since his I&O is 1350/500. You've been a big help! Thank you!

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.
sounds lots better than mine! =)

another one that i came up with was risk for imbalanced fluid volume related to intake in excess of output. does that one work? i thought about it since his i&o is 1350/500. you've been a big help! thank you!

sounds good to me.

remember that diagnosing relies on the evidence you have. every nursing diagnosis has a set of defining characteristics. the patient must have at least one or more of them in order to be labeled with that diagnosis. it also helps to read the definition of the diagnosis as well. the nursing diagnosis itself is only a shortened label.

Up Vote Up Vote ×

Do you have a nursing diagnosis handbook. We were required to purchase one before classes started. If you read the "How to Use This Book" section it will really speed up the process for you. For example in the front of my book is a section listing various medical diagnosis. (the patients chart should have a admiting diagnosis on the face sheet). Look up this diagnosis and it will list various Nursing Diagnosis associated with this Medical Diagnosis (they are different, your instructors will beat this into your head).

Then flip to that nursing diagnosis in the book. It will list "defining characteristics" for example the deginig characteristics for Ineffective Denial are Delays seeking or refuses health care attention to the detriment of health; does not percieve personal relevance of symtoms or danger; displaces source of symptoms to other organs .........

If you can see actual references to these defining characteristics on your patients chart boom there you go.

If the book doesnt have that medical diagnosis. Look for something similar and work from there.

Remeber P R I O R I TY when you list your diagnosis put the ones that will kill your patient/disable your patient first. Actual diagnosis before potential diagnosis.

Impaired skin integrity secondary to incontience

At risk for social isolation

Then you run into isues of maslow ........ Your instructors can handle all that. Good luck, study hard!

Up Vote Up Vote ×
+ Add a Comment