Careplan Craziness

I need help please! I'm trying to come up with nursing diagnoses for my pt wth increased bilirubin, ileus, pleural effusion, and ascites. My problem is, I keep coming up with more "risk for" than actual problems. Also, our diagnoses cannot be collaborative. Is any of this making sense because I'm starting to feel crazy! Any help from anyone will be greatly appreciated.

[tachybradyRN]

You should probably list more data, i.e.:

Patient's age/gender

PMH/PSH

Current problems & comorbidities

Just based off a few medical diagnoses, it's very hard to come up with NDs.

[Daytonite, BSN, RN]

don't know what risks you are coming up with. your patient has 4 real problems:

• increased bilirubin
  
• ileus
  • hypoactive bowel sounds
    
  • abdominal cramps
    
  • periumbilical pain
    
  • abdominal distension
    
  • nausea/vomiting (bile or fecal color)
    
  • constipation with diarrhea

  [*]pleural effusion

  • dyspnea
    
  • visible tracheal shift
    
  • diminished or absent breath sounds over the effusion
    
  • pleural friction rub

  [*]ascites

  • change from tympany to dullness when percussing the abdomen
    
  • detecting a fluid wave traveling along the abdominal wall when striking one side of the abdomen
    
  • abdominal fluid shifts to the most dependent part of the abdomen

what are the symptoms (abnormal assessment data) you found in the patient for these conditions? the ileus and ascites are probably related and have something to do with either fluid retention or fluid loss. what's going on with the pleural effusion? does this patient have cancer of the lung? cancer of the liver or some other liver disease? when i see increased bilirubin i think about jaundice and/or anemia.

nursing diagnoses are based upon the symptoms that a patient has. all nursing diagnoses have a list of symptoms--nanda calls them defining characteristics. you cannot assign a nursing diagnosis to someone without having the symptomatic evidence to back it up. that evidence comes from your assessment of the patient and information you collected from the chart.

there is information on writing care plans on this sticky thread:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing discussion forum)