Care Plan ...I feel like im missing info so Im lost...PLEASE HELP

[NecieK]

So i have my first care plan due and its not on a real patient so the only assessments I come up with are from paper, here it goes.

ICU floor 45/F diagnosed with colon cancer which seems to be caused from a tumor in her ascending colon. She has abdominal distention (assessment #1 possibly paralytic ileus??)[/u] her hemoglobin is 8 and hematocrit is 30 (assessment #2 anemic). She is NPO. She has an NG tube for decompression. (im feeling like she is more then likely post op ?)She has an infusion of saline 5% hanging at 100cc/hr . And she has rales and rhonchi to the right and lower left lobes.

Ok so we know she has:

Colon Cancer

Abdominal Distention

Low HgB and hemotocrit....Is this caused from surgery or the cancer ??

She has a distended abdomen...Same question as above

And she has rales and rhonchi

So im thinking my Nursing Diagnosis should be:

#1 Imbalanced Nutrition: less than body requirements related to ??? AEB Low blood counts

#2 Airway clearance, ineffective related to retained secretions AEB rales and rhonchi.

#3 Skin integrity, risk for impaired related to decrease in nutritional intake.

Any help would be so appreciated , Im extremely frustrated

[CuriousMe]

Great job, you're on the right track!!! Of the three problems you identified....which, if it got much worse, would impact your patient's ability to sustain life?

[NecieK]

Airway clearance right??

[CuriousMe]

right, so you'll want to go ahead and prioritize that one.

As we don't know for sure that she's post-op, I don't think I'd put down risk for infection.

[NecieK]

Nooooooo !! AHHHHHHH now i feel real stupid lol

Infection

[JulieCVICURN, BSN, RN]

I'd also include risk for aspiration somewhere in there. If you have a paralytic ileus there's a serious risk of vomiting and aspirating. I see it more than I'd like to admit.

[NecieK]

But do we know for sure she is even post op, or are we looking into it too deep...I think thats what makes this so confusing kwim?

[AggieNurse99, BSN, RN]

A few points to consider - NG suction - also suctions out all stomach acid, right? Can cause metabolic alkalosis. What steps are being taken to prevent this? H/H of 8/30 - anemia. Why is anemia a problem too? And she's on NS @ 100 ml/hr, so is the anemia going to get better or worse? Doesn't matter at this point why she's anemic. My guess is that she's had a hx of poor PO intake d/t abdomnial distention & discomfort. Go back to assessment 101. What do rhonchi and rales signify?

[elizabeth321]

well i haven't done care plans for a long time but as a nurse I am thinking about :

no K replacement ordered?

if is he in ICU she must be post op intubated....otherwise why would she be there? sepsis?

she isn't getting enough volume for NPO and losing fluids by NG

the anemia number can be exaggerated by the fact she is dry

if her abdomen is distended that is a red flag because either her ng is not working or her vent

she is also at risk for pneumonia due to not moving...tubed....

I liked the problem you had for nutrition and skin integrity but there are billions more

[CuriousMe]

I'd be careful about reading to much into it. It's that whole realworld/NCLEX world dilema :)

Things that aren't listed:

Post-op or not

Intubated or not

I'm with AggieNurse....I'd stick to your assessment findings and follow up with the rales & Rhonchi

[NecieK]

Ok done and sent off to the teacher...Ill let yall know when I get my grade how it went....And BTW THANKS!!!

[elizabeth321]

so what happened?