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Discussion

Help with care plan!

I need help with my care plan.. I only had my patient for a few hours and really don't have all of my info that I think I need to have a good care plan and my patient didn't speak english! He came in with a small bowel obstruction and ended up having an ileostomy.. my instructor is super strict with care plans and I need to make sure this ones good. For my first nursing diagnosis I have Acute pain r/t intestinal obstruction AEB grimacing, splinting, patient stating pain 5 out of 10, second diagnosis is Imbalanced nutrition: less than body requirements r/t decreased ability to ingest food AEB client expressing a lack of interest in food and I have no idea for a third :( I would have liked to do something with imbalanced fluid volume but my patient got discharged my second day and I didn't get to look up any of his labs so I dont have anything to back that up.. any help would be appreciated

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    I found this website that seems to be a really helpful reference. I posted the link below:

    10 Ileostomy & Colostomy Nursing Care Plans | Nurseslabs

    As I said, you can use it as a reference to get an idea of what other goal you want for your patient then elaborate from there. I hope this helps :)

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    Get yourself a care plan book at a bookstore, they have all you'll need

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    • Author

    I have a few care plan books and nothing is helping! My instructor is just so strict with these and I have no idea what to do

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    What are you thinking with the data that you do have rather than what you are missing?

    What about deficient knowledge or readiness for enhanced knowledge r/t self care of ileostomy and post op/discharge regimen?

    Risk for dysfunctional gastrointestinal motility? (Defined as at risk for increased, decreased, ineffective or lack of peristaltic activity within gastrointestinal system) or dysfunctional gastrointestinal motility (depending on your assessment)

    If you look at the list of defining characteristics for deficient fluid volume you don't have to know labs as long as you have good physical assessment data

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    "deficient knowledge or readiness for enhanced knowledge r/t self care of ileostomy and post op/discharge regimen?"

    That's a good one....and you do not need labs for this one

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    • Experts

    thread moved for best response.

    Care plans are all about the assessment of the patient. What was your assessment? What semester are you?

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