Specialties Med-Surg
Published Mar 25, 2015
lnxyourxeyez
17 Posts
Hello. I am having some trouble with my careplan.
So I have a patient that came in for laparoscopic cholecystectomy, a week later the patient was readmitted for peritonitis - they did a CT scan and found a small-bowel injury that mustve occurred during the laparoscopic cholecystectomy. They did a small bowel resection and an anastomosis. The patients leukocytes were high so they did a second CT scan and it showed residual fluid collection and air bubbles under the diaphragm and pelvic cavity.
She has 3 drains right now, still having drainage.
I thought Fluid Volume Deficit, but are there any other diagnosis ?
Also, what are the most IMPORTANT things to assess / intervene for this patient?
Sorry I'm kind of new to this and I want to expand my brain and think as much as possible but I'm having a brain cramp
Levitas, BSN, RN
185 Posts
There are always the basics that will likely apply to most patients.
Risk of Injury
Knowledge Deficit
Ability to return to previous living arrangements
Some others that could apply to your patient:
Infection
Risk of infection
Nutritional deficit
Alteration of comfort
Are you at work now? We usually have to complete a care plan on admission, and our admission has to be done within 24 hours of the patient hitting the floor (started within 4 hours). I don't know how it is at your facility, but at ours, we can start a care plan, and any RN can go in, and edit/add/remove as needed at a later time.