Care Plan!

[christina44]

Hi, I am trying to figure out appropriate nursing diagnosis for a 43Y female who was recently diagnosed with lymphoma of the brain. she c/o headaches, nocturia and her only hx is back problems. She is also recieving chemo. For my nursing diagnosis's so far I have:

Pain

Impaired physical mobility

impaired oral mucous membranes r/t side effects of chemo

risk for infection: risk factor inadequate immune system, and

impaired urinary elimination

I would like some help on coming up with one more "creative" nursing diagnosis. Thank You!! :)

[Daytonite, BSN, RN]

the choice of a nursing diagnosis is based on abnormal assessment. i won't diagnosis without that information. you've only provided information about the medical diagnoses and medical treatment and nursing diagnoses for the two symptoms you did list. i suggest you consider assessing the person's other adls (at minimum: bathing, dressing, mobility, eating, and grooming) and cognitive abilities.

[christina44]

Hi, thank you for your response. I wasn't able to meet or do any of those assessments ahead of time when I had to figure out these nursing diagnosis. I was only allowed to view the chart. I got the chance of working with her today however, and she is very independent. She can do all ADLs independently, mobalize safely, independently bath, eat, dress etc. She was alert and oriented x4 and she had no cognitive abnormalities. She is extremely healthy, a nurse, and very positive about the situation, which is why I found it hard to come up with diagnosis's for such a healthy individual. She is coping with the cancer well and got to go home today on a weekend pass. She is worried about her BM's though, so I am going to add on a nursing diagnosis of risk for constipation, as it has been 3 days since her last BM (when she regularly has one a day). I would love to hear if you have any other ideas though, and thank you for your help!

[UM Review RN, ASN, RN]

I'm not the greatest at care plans, but I'd guess going x3 days with no BM and usually having 1 qd is normal, that she isn't "at risk for" but just plain "Constipation aeb no BM x 3 days."

[Daytonite, BSN, RN]

For the future, when you have to come up with nursing diagnoses for a patient site unseen but you have had access to some information from the chart, you work with that information. Since she had lymphoma of the brain and complained of headaches and nocturia and had a history of back problems you use that information. Look up the signs and symptoms of lymphoma of the brain and see what they lead you to for possible nursing diagnoses. The headaches, back problems and nocturia are already symptoms you can work up nursing diagnoses for. And, lastly, look up the side effects that generally occur with most chemotherapy agents. That is pretty much what it looks like you did.

The care plan can be modified after you complete you assessment after you actually meet and work with the patient. Diagnoses are always based upon evidence that you have to support them. If she hasn't had a BM in 3 days then she is not at a Risk for Constipation, she already has it. Any idea why? Is it because of the chemotherapy or has she just not been eating enough? There is a diagnosis called Constipation.

I would also look at the side effects of the specific chemotherapy drugs she is getting as each have certain problems aside from interfering with the normally rapidly dividing cells of the body (that's where you get the hair loss, vomiting and diarrhea, low blood counts). There was a reason she was admitted to the hospital. Even if it was for testing she is not taking up a bed to watch soap operas. She's there for a reason, for monitoring, treatment, or testing and the nursing care was needed and part of it otherwise they could be doing things for her on an outpatient basis.

[christina44]

Okay thank you, yeah she was just staying in the hospital pretty much to recieve her chemo treatment because she lives 2 hrs out of town. But I have figured it all out, thank you so much for your time and helping me.