Help with Diagnosis--Care Plan

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Case Study

Carla Dillon is a 70 year old frail Caucasian female with a 5 day history of intractable vomiting, fever ranging between 101-102 F, and non-specific back pain. Over the past 2 days, she has had 5 liquid stools per day and can not tolerate a regular diet.

Chief Complaint: "I ache all over and can't seem to keep any food down. I can't afford to lose any weight."

Abnormal Lab Values report:

CBC with Diff

WBC: 22,000 (H) RBC: 6.1 (H)

Lymphocytes: 67 (H) HCT: 55% (H)

Hgb: 18 (H)

Chemistry

Na: 133 (L) BUN: 22 (H)

CO2: 12 (L) Creat: 27 (H)

Glucose: 52 (L)

Urinalysis

Color: dark amber Culture: pending

Specific gravity: 1.035 (H) pH: 8.5 (H)

Cultures

Stool: pending

Blood: pending

Admitting Orders:

Admitting Dx: Dehydration 5%, Fever

Diet: Clear liquid, advance as tolerated

Vital Signs every 4 hours

Strict I&O's

IVF: D5LR to run at 100 mL/hr

Medications:

Lopressor: 100 mg PO once a day MVI: 1 tab PO once a day

Tylenol PRN for temperature over 101

Admitting Assessment:

General Survey: Frail 5 ft tall, 100 lb elderly female. Presented to ER and arrive to floor alone with an emesis basin. Face pale in color. Currently, shivering uncontrollably.

Vital Signs: Temp: 102 F (oral), Pulse: 128 (bounding, regular), Resp: 30, BP: 98/52, O2 sat: 96% on RA, Pain Scale 2/10

Skin: Face pale. Warm, flushed with decreased turgor.

Neuro: EOM's sluggish

Thorax: Apical pulse 120 strong, regular. Respirations 30 equal chest rises, labored with slight use of accessory muscles

Abd: tender to touch with hyperactive bowel sounds. Last bowel movement in ER; loose to watery brown with foul odor

GU: No discharge or odor noted. Last void in ED of 100 ml of urine

Extremities: Ambulates with walker.

Psychosocial: Retired school teacher. Husband died last year. Son lives out of state. Lives alone in retired community, but has many friends and is active within her community.

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Tell us a little bit about what you've done and what you need help with. If you need nursing diagnoses for a care plan, there are a couple that should jump out right away. Do you have any ideas? People will help you from there.

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Specializes in Home Health.

I'm sure it isn't, but I hope that isn't the patient's real name.

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Yes I came up with 20 options for a Diagnosis.

And no it's not a real pt or their real name.

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Ive written down all of those Dx already.

I just need to know how to word it in the care plan.

Then I have to narrow the Dx to the top 2 most important Dx.

I would think the top 2 would be Nutrient: less than body requirement, imbalanced and Fluid Volume, Deficeit.

This is all of the Dx I came up with.

Can you tell me the top 2 you think would be relavent for this patient?

Nursing Diagnosis

  1. Nutrition, less than body requirements, imbalanced pg.194
  2. Diarrhea pg. 248
  3. Breathing Pattern, Ineffective pg. 307
  4. Body Temperature, Imbalanced, Risk For pg. 139
  5. Grieving, Anticipatory pg. 646
  6. Community Coping, Readiness for Enhanced pg. 756
  7. Family Coping, Disabled pg. 760
  8. Pain, Acute pg. 486
  9. Walking, Impaired pg. 408
  10. Falls, Risk For pg. 336
  11. Cardiac Output, Decreased pg. 312
  12. Urinary Incontinence pg. 254
  13. Bowel Incontinence pg. 236
  14. Thermoregulation, Ineffective pg. 212
  15. Nausea pg. 188
  16. Hyperthermia pg. 176
  17. Fluid Volume, Deficient pg.151
  18. Body Temperature, Imbalanced pg. 139
  19. Injury, Risk For pg.59
  20. Health-Seeking Behaviors pg. 49
  21. Infection, Risk For
  22. Knowledge Deficeit
  23. Fear
  24. Anxiety

If you guys could help me Id greatly appreciate it!

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