Help 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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Specializes in Medical Surgical/Addiction/Mental Health.

First, you did an excellent job of gathering the necessary information.

Now, ask yourself this question: My patient has been vomiting for the last five days. What are the potential outcomes of her condition.

She was admitted for dehydration. Because of the color of urine and gravity results, she IS dehydrated. So, “Fluid Volume Deficit” is a start to your careplan. “Infection” is another Dx (Not risk for because her white count is elevated). If she is not rehydrated, you will run into problems with electrolyte imbalances (i.e. the Na) If she is vomiting profusely, then she runs the risk of Metabolic Alkalosis (she is losing acid from her stomach, so she will eventually become alkaline). Her Ph wasn’t off? I would think she would be a little above 7.45.

Anyway…I hope this is enough to get your started or at the very least an idea of how to look at the information to develop a nursing Dx.

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wow, this lady sure has lots of problems...

by glancing through it I can come up with some diagnoses in my head:

Acute Pain

Ineffective Breathing Pattern

Nausea

Diarrhea

Risk for Fluid Imbalance

Risk for Falls

Risk for Infection

Hyperthermia

Imbalance Nutrition: less than body requirements

Anxiety

Fear

Knowledge Deficit

Those are diagnoses and problems that she probably has. Just make sure you have all the data to back it up. Good luck!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

an excellent resource.....

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

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Thank you guys so much.

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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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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