Help with careplan please!!!!

[miniangel729]

we need to do a concept map in our careplan,

my patient came in from er complaining of worsening of abdominal pain (mid epigastric area). she's been having mid. abdominal pain on and off for the past few months. she was admitted yesterday nov. 1 with symptoms of n/v, anorexia, fever and abdominal pain.

patient is kept on npo since yesterday, i asked the nurse she said its due to her n/v and will stay on npo until further tests are being done.

the dr. diagnosed her with 1. gallstone acute pancreatitis

2. choledocholithiasis with secondary intra- and extrahepati duct dilatation.

3. bacteruria.

patient's h&h and platelet droped significantly just in one day, could it be because of poor nutritient diet? since shes on npo. (i couldn't find it on the lab value book =/)

and what kind of nursing dianosis & intervention could i make..?

- acute pain?

- imbalanced nutrient, less than body requirement? (pt's on npo, what kind of intervention could i do for her?

- nausea

[Daytonite, BSN, RN]

nursing diagnosis is based on your assessment of the patient. assessment includes:

• a physical assessment of the patient
  
• assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
  
• data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
  
• knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
  
  • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

this patient has the following medical conditions and treatments:

• gallstones
  
• acute pancreatitis
  
• choledocholithiasis
  
• secondary intra- and extrahepatic duct dilatation
  
• bacteruria
  
• low h&h and platelet count
  
• npo

determination of the patient's problem(s)/nursing diagnosis is based on the patient's response to what is happening to them (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use) these are signs and symptoms you noted:

• n/v
  
• anorexia
  
• fever
  
• abdominal pain (mid epigastric area)

just as every medical diagnosis has a set of signs and symptoms, every nursing diagnosis has a set of what are called defining characteristics (signs and symptoms). to assign any nursing diagnosis to a patient, at least one or more signs and symptoms must be present. the patient's behavior also should match the definition of the nursing diagnosis. this information (the definition and defining characteristics) for each nursing diagnosis is part of the nanda taxonomy of the nursing diagnoses.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

nursing diagnoses might be:

1. imbalanced nutrition: less than body requirements r/t inadequate intake aeb anorexia, nausea, vomiting and required npo status
   
2. hyperthermia r/t inflamed gallbladder and pancreas aeb fever [+ other symptoms of elevated body temperature]
   
3. acute pain r/t inflammation and swelling of gallbladder and pancreas aeb patient complaint of abdominal pain

patient's h&h and platelet dropped significantly just in one day, could it be because of poor nutrient diet?

probably due to dehydration as a result of fluid losses because of the nausea and vomiting.