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
What were your instructions for the care plan. In the beginning we only had to give one nursing diagnosis with three interventions? Are you required to give multiple nursing diagnosis? Either way, it sounds like you are right on track. Based on my experience you just need to keep it simple for now.
D.R.A.
207 Posts
What were your instructions for the care plan. In the beginning we only had to give one nursing diagnosis with three interventions? Are you required to give multiple nursing diagnosis? Either way, it sounds like you are right on track. Based on my experience you just need to keep it simple for now.