careplan help

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Need help with careplan on:

older gentleman, hx of diabetic, GI bleed (not active) low H&H, post-op X2 days pacemaker placement, I am having trouble with a nurs dx for the GI bleed, hem is 8.2, HCT is 25. Can anyone point me to the right direction. Thanks

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hi, wildwildmustang!

your care plan is the written expression of the nursing process. remember that the steps of this are as follows:

  1. assessment
  2. nursing diagnosis
  3. planning
  4. implementation
  5. evaluation

the only actual assessment data that you've provided here is that the patient has a hemoglobin of 8.2 and hematocrit of 25. these are symptoms of the hemorrhage and can be used to develop a nursing diagnosis. i'm guessing this is not a real patient. am i correct? if that is so, then what you need to do is take a step and turn all the medical diagnoses into symptoms in order to determine what other nursing diagnoses you might come up with.

to get back to a nursing diagnosis for the hemorrhage, however, patients who are sustaining hemorrhage whether it be frank bleeding or slow leaking have one thing in common. their body fluids are imbalanced. and, there just happens to be a nursing diagnosis that covers that.

your nursing diagnostic statement would be:

deficient fluid volume
related to blood loss as evidenced by hemoglobin of 8.2 and hematocrit of 25

in this case the cause of the fluid volume deficit is the hemorrhage. however, you don't want to use that term as it is a medical diagnosis. the hemoglobin and hematocit levels are evidence supporting the condition.

your next step would be to determine outcomes and then nursing interventions. one very general outcome is going to be to treat the current fluid volume loss and/or prevent any further losses. however, this may not be doable. many times slow gi bleeding is difficult for doctors to detect even after performing upper and lower endoscopies.

i would strongly suggest that you obtain a current nursing care plan or nursing diagnosis handbook to help you with subsequent care plans and determining nursing diagnoses. this care planning process is a basic function of nursing and you will be doing it from now until you retire from nursing. this is one of the primary skills you are going to be learning in nursing school.

here are sites where you can see the definition of this nursing diagnosis, related factors (causes), defining characteristics (symptoms), outcomes and nursing interventions:

i saw that you had originally posted this in the "desperately need help with careplans" thread on this forum, so i know you have probably read through many of the posts on that thread. here are two other threads on allnurses that you might find helpful as well:

good luck with your future careplan writing! welcome to allnurses! :welcome:

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