Help with my care plan! (Colon Cancer)

[ACKrissy]

Okay, I need some help with my care plan (this is my first time). I had a 54 y/o female patient who had colon cancer. She had surgery (laparoscopic-assisted ileocolic resection) to remove the cancer 2 days before I was there. She has no other medical problems... the only deviations in her labs were her RBC, Hct, Hgb were low (3.14, 28, 9.0, respectively). The night I went there to do my paperwork, she was on an IV and clear liquid diet. However, the day I went there (the next day), they d/c ed her IV, and she was on a full liquid diet. I looked in my care plan book and I came up with one diagnosis: Acute pain R/T surgical incision...but I need help with another (we aren't allowed to have "psych diagnoses"). I thought about Imbalanced nutrition: less than body requirements, but I am not sure if that's the next priority. Any help would be much appreciated!!! Thanks!

[Daytonite, BSN, RN]

please read these three posts:

• https://allnurses.com/forums/f205/help-nursing-care-plans-277791.html
  
• https://allnurses.com/forums/f8/desparately-need-help-care-plan-279187.html
  
• https://allnurses.com/forums/f205/appy-195227.html#post1969425

you must follow the steps of the nursing process in their sequence in writing a care plan. you cannot start off with picking nursing diagnoses until you have laid the groundwork to do that first. the groundwork for that is step #1 of the nursing process--assessment. you have to have done a thorough assessment and go through that assessment data to develop a list of your patient's symptoms. your assessment activities in this particular case should also include knowing what the complications of undergoing general anesthesia are. you also need to know what is involved in colon surgery and what is expected to happen with the patient who has had colon surgery in the immediate post-op period.

the only symptoms i can glean from the information you've posted are that the patient has surgical pain and a low hemoglobin and hematocrit. because i've had colon surgery for colon cancer i know there are some things you've missed. this lady isn't up and about and turning cartwheels. did you assess her ability to perform her adls? is she bathing, dressing, walking, eating, grooming and toileting entirely by herself? or, is some help needed? these would be self-care deficits. is she passing any stool yet? people who have had colon surgery come out of surgery with a bowel that has no peristalsis going on. that is an abnormal situation that can lead to eventual constipation or the third spacing and loss of fluids. in addition, these patients don't get solid food or discharged until (1) they are passing flatus, and (2) they poop. and, that needs to be monitored and assessed on a regular basis. that is why the surgeon and all the nurses are constantly listening to her bowel sounds and asking her if she has passed any gas or had a bm. so, what was her abdominal assessment? since she had a laparoscopy, what do the laparoscopy wounds look like? they need to be assessed and monitored. these are tissue integrity issues. she underwent general anesthesia. what were her lung sounds like? did she have a sore throat from the presence of the et tube in her airway? is anyone having her deep breathing and coughing? is she bringing up any sputum? she should be by day 3, even if it's a small amount. any presence of these kinds of things are problems that become symptoms that you can care plan for.

re-think your list of your patient's symptoms and i believe you will find a lot more there to care plan for than you thought. if you are having trouble turning symptoms into nursing diagnoses, post the list of symptoms and i will help show you how to determine the problems (nursing diagnoses).

[CindyWeaver]

Imbalanced nutrition, less than body requirements related colon surgery as evidence by liquid diet. Patient will need to have intake and output measured, weigh daily and consult dietician.

[Mike R, ADN, BSN, RN]

I gotta agree with Daytonite. Did you do a physical assessment and what were the findings?

[julieweiss1210]

you need to list your patient's signs and symptoms in order of most importance. there are also severall very informative text you can research for good information and step by step guidance in developing a proper care plan.

julie bettura

[leslie512]

You should do a complete assessment on your patient and determine from that point what the 3 major issues are with your patient. A nursing care plan book can give you some great ideas. Good Luck!