First time writing a care plan... help?

[holaitsdee]

Hello everyone,

I am a first semester student and I missed one of my clinical days so I was given an alternate assignment to complete, which is a care plan! We haven't done any yet or been taught how to do them so I am struggling HARD. I struggle with writing nursing diagnosis, especially the R/T and AEB parts, so if you could guide me into the right direction I would really appreciate it!

About my "patient": 75 years old woman, came in with severe right lower quadrant pain and had an emergency appendectomy 2 days ago. She had an indwelling catheter which was removed 24 hours successfully. She has become confused and easily startled over the past 24 hours.

She was alert and oriented x4 and now is down to x2 and needs further assistance with ADLs due to midline surgical incision, but was able to perform her own unassisted ADLs before. She has tried to get up without assistance twice and is now on fall precautions. One hour after being monitored for falls and with 3 bedrails up, patient is now combative. Her abdomen was soft but has become distended after 6 hours post foley catheter removal. Hasn't had bowel movement in 4 days when usually she does every other day. Previous vital signs: 98 70 16 130/85 and now they are 98.9 90 18 140/90. Complaining of fullness to abdomen, inability to void and abdominal discomfort.

I have to come up with 3 nursing diagnosis and 2 at risk diagnosis. What I have so far:

1) Constipation R/T abdominal muscle weakness secondary to appendectomy AEB lack of BM in 4 days, distended abdomen and abdominal discomfort

2) Impaired urinary elimination R/T Foley catheter removal AEB patient's inability to void.

3) I want to do one surrounding her sudden confusion (acute confusion?) but I'm unsure how to set it up.

As for my at risk diagnosis, could I do at risk for falls even though she is already on fall precautions? And could I do risk for infection related to use of indwelling catheter and recent midline surgical incision?

Thank you in advance!

[JKL33]

Very good!

For your acute confusion dx, you have most of the information to write it; what would you put for the "r/t?"

Yes you can also use the other risk diagnoses you mentioned.

[amoLucia]

Please don't underestimate PAIN even in elderly pts. She is post-op and pain could be contributing to the confusion (as well as UTI and constipation).

Any new meds?