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
