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careplan help for a pt. with gastric ulcer, anemia, UTI

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by mhelyza mhelyza (New) New

hi there! just need some help with my care plan..

my patient for a case study is 43 years old. he is morbidly obese, bedridden, with a decubitis ulcer.

i was wondering what nursing diagnosis i could use for his UTI secondary to perianal fistula. he has dysuria, hematuria, normal urea & creatinine. his UA showed:

Ketone=trace

Blood occult=++

Protein=+

Nitrate=(+)

Leukocyte=+++

WBC=innumerable

Bacteria=++++

and with stool in urine

i don't know if i could use Impaired Urinary Elimination because his urine output is ok, and he doesn't have a catheter.

i need 6 nsg. dx.. here's what i have done already:

Ineffective Tissue Perfusion R/T decreased oxygen-carrying capacity of the blood

Pain R/T gastric mucosal damage

Imbalanced Nutrition: less than body requirements R/T poor appetite

Risk for further Infection R/T decreased Hemoglobin and immune system function

and other choices I have:

Ineffective Health maintenance R/T lack of material resources

Risk for Injury (Allergy) R/T Blood transfusion

i know he has so many problems to deal with. but i think it would be better if i could have a care plan for his UTI (an actual problem), instead of just risks.

do you think i should also do a care plan for his skin integrity? because he is obese, and with decubitis ulcer already.

my focus on the study is his gastric ulcer & severe anemia

sorry if i may have missed other information..

THANKS A LOT!!!

TakeTwoAspirin, MSN, RN, APRN

Specializes in Peri-op/Sub-Acute ANP.

Just some thoughts off the top of my head that may be helpful.

I agree with you that you should prioritize starting with his current problems first.

As I see it he also has "mobility, impaired physically" r/t his morbid obesity.

Because he has an ulcer, he is also at risk for infection from this.

Because he already has skin breakdown, poor mobility, and is morbidly obese I think it would be wise to include a plan for maintaining/improving skin integrity.

If I am reading correctly, you indicate that he has stool in his urine which would indicate that the fistula has extended from bowel to bladder/ureters/urethra somewhere. In which case, the patient will have to be evaluated by a surgeon to have this repaired.

You may evaluate whether his ulcer is still bleeding by doing fecal occult tests per facility protocol. He may also need to have an endoscopy at some point, requiring a consult with a gastroenterologist.

Considering that he is morbidly obese, then your dx "Imbalanced Nutrition: less than body requirements R/T poor appetite" may need refining.

He may be currently suffering from anorexia, but his "long term" dx. would be "imbalanced nutrition: more than body requirements a/e/b BMI of ....."

Hope this gives you some food for thought (no pun intended), but I am sure others will chip in with things I have missed.

You seem to be off to a good start though.

TakeTwoAspirin, MSN, RN, APRN

Specializes in Peri-op/Sub-Acute ANP.

Almost forgot, given all of his problems he is definitely at risk for falls and you do not want to be picking him up off the floor!

ok, got that down :)

thanks a lot! really helpful =)

gotta run.. still piled-up with so many things to do.. :D

btw, i chose the "less than body requirements" dx because he has been anorexic for 2 months already prior to his hospitalization. and his wife estimated his weight loss to be about 50+ lbs already since then. is it still inappropriate to use that dx?

he was also advised to have more tests because his gastric biopsy was found to be an adenocarcinoma. but they lack financial resources, so he just requested to be discharged already.. aww, so sad.. i dunno though if that's connected to what i posted.. haha!

tnx again!

TakeTwoAspirin, MSN, RN, APRN

Specializes in Peri-op/Sub-Acute ANP.

Mhelyza,

OK I have a better picture now. Your dx about "less than body requirements" given that he has had anorexia x2 months and has a weight loss would be correct. It's easy to forget sometimes that you can be overweight, and still be malnourished and it is likely at this point that your patient is malnourished.

Given that you have shared that the pt actually has adenocarcinoma, although terrible for the patient, gives you a couple more dx categories that you can work on related to his mental status, ie., defensive coping, risk for social isolation, ineffective therapeutic regiment management, self-care deficits, disturbed body image, chronic low-self estime, anticipatory grieving, death anxiety, etc.

With a fistula between his bowel and some unknown part of his urinary system, he is off the scale with risk for severe infection including peritonitis, nephritis, etc so you should look at possible risk dx for these conditions too.

This is a very sad case, but you should have no trouble getting enough to work on an extensive care plan given all that is going on.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

hi, mhelyza, and welcome to allnurses! :redpinkhe

a care plan is based upon the symptoms the patient has and not necessarily upon his/her medical diagnoses. the medical diagnoses are important in that you need to know the pathophysiology of what is going on with the disease process and how it is affecting the body systems. a care plan in nothing more than written documentation of your problem solving process. there are 5 steps to this problem solving and you really need to follow them in their proper sequence.

  1. assessment (collect data from medical record and by doing a physical assessment of the patient)
  2. nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

step #1 if this were a real patient would be to review their medical record and perform an interview and physical examination. since this is a case study you have to use and expand on the information you were given. this patient is

  • morbidly obese
  • has a perianal fistula
  • has a decubitus ulcer (sacral?)
  • has a uti
  • has a gastric ulcer?
  • has anemia?

the first thing i would recommend that you do is look up these medical conditions and find out as much about them as you can. specifically, make a list of the signs and symptoms associated with each of them since you need those signs and symptoms in order to be able to choose nursing diagnoses. you cannot arbitrarily start choosing nursing diagnoses for a patient based upon their medical conditions. doctors don't do this. they base their choice of any medical diagnosis on the patient's symptoms. you will base your choice of nursing diagnoses on the patient's symptoms as well. but first, you have to develop a list of those symptoms. so far, you only have a handful and there are many more that you should be able to come up with after reading about this patient's medical conditions.

in step #2 of the care plan process you make a list of your patient's symptoms. with that list you are going to look through the nanda taxonomy (the listings of nursing diagnoses, their definitions, defining characteristics also known as symptoms and related factors) for defining characteristics associated with nursing diagnoses that are going to fit with this patient's various symptoms, actual symptoms he/she is having. these are the symptoms you listed (however, i know you could find more after doing some reading):

  • bedridden
  • decubitus ulcer.
  • perianal fistula
  • dysuria
  • hematuria
  • trace ketones in the urine
  • occult blood in the urine
  • 1+ protein in the urine
  • 1+ nitrate in the urine
  • 3+ leukocytes in the urine
  • 4+ bacteria in the urine
  • stool in the urine

why would a patient have ketones in their urine? usually because they are starving (utilizing glycogen in their liver and their stores of fat because they are not taking in enough calories). that means there is a nutritional problem going on here. so, you need to look up the symptoms of starvation and ketonemia in order to find the symptoms that are going to get you to use imbalanced nutrition: less than body requirements r/t inability to ingest food

by far, the symptoms of urinary problems stand out in your post. there is currently only one diagnosis that you could use: impaired urinary elimination and the only symptom on your list that qualifies you to use this diagnosis is that the patient has the defining characteristic associated with this nursing diagnosis of dysuria (page 234, nanda-i nursing diagnoses: definitions & classification 2007-2008) [here is a web page where you can see the nanda information on this nursing diagnosis: [color=#3366ff]impaired urinary elimination]. the related factor that nanda lists with this nursing diagnosis that would be appropriate to use is the urinary tract infection. so, your nursing diagnosis for this would be written as: impaired urinary elimination r/t urinary tract infection aeb dysuria.

this patient has an open wound--the decubitus ulcer. you missed this because you don't have the symptoms of a decubitus ulcer listed. i am not clear whether this patient's fistula belongs to the decubitus ulcer or if the decubitus ulcer and the fistula are two separate things that the patient has. i'm going to assume the fistula is a complication of the decubitus ulcer. the appropriate nursing diagnosis to use for stage 3 or 4 decubitus ulcers is impaired tissue integrity r/t pressure.

now, you have a lot of other lab information suggesting some other things going on that are also related to the uti. however, you also lack the other symptoms of a uti. people with a uti often have hematuria, pain with urination, pain over the bladder area, cloudy and foul smelling urine and perhaps a fever. where are those symptoms? you need to include them, don't you think? that is part of doing a case study. that is why i'm telling you that you need to look up information about the patient's medical conditions and the symptoms associated with them. with

  • hematuria
  • pain with urination
  • pain over the bladder area
  • cloudy and foul smelling urine
  • fever

you can have these nursing diagnoses

  • acute pain r/t urinary tract infection
  • hyperthermia r/t urinary tract infection
  • risk for infection [not likely since you already know the patient has a uti]

this patient is also bedridden. this is a basic adl (activity of daily living) problem of mobility. this is an underlying etiology (cause) of the decubitus ulcer. there are a number of mobility diagnoses and you need to classify this correctly. if the patient is already bedridden impaired bed mobility may be appropriate to use. you need to look up the term "bedridden" and learn what it means and what the symptoms of it are. if you look at the nanda references for this diagnosis you will find that you can use this: impaired bed mobility r/t morbid obesity for this patient. the definition of this diagnosis is "limitation of independent movement from one bed position to another." that sounds to me like it would be appropriate to use for this patient.

the most important thing i want to stress to you is that if the patient doesn't have the symptoms, then you can't tag them with any specific nursing diagnosis. doctors can't do this with medical diagnoses either.

now, i've given you 4 solid nursing diagnoses you could use for this patient and 2 other potential ones. however, they depend on your doing some work of looking up information on the signs and symptoms of the patient's medical conditions. in step #3 of your care plan you will write goals and nursing interventions. the reason for knowing what your patient's symptoms are is that your goals and nursing interventions are entirely focused on those symptoms--and you must be able to list them out. there is a rational flow to the information that goes onto your care plan and it all fits together like a key goes into a lock or all the parts of a puzzle fit together to make a picture.

i've given you a start as to how to proceed with this case study. you have a great deal of work you have to do on this yet.

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