Help with Nursing Care Plan

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I need to do a nursing care plan for the first time. My patient is a 90 year old female, disoriented, in the hospital for gallstones.

The nursing diagnoses I cam up with are:

· Acute Pain r/t to gallstones as evidenced by pain of 6 on 0-10 scale and guarding

· Impaired Tissue Integrity r/t altered circulation a.e.b. pressure ulcer stage 1

· Risk for Infection r/t surgical site

· Bowel Incontinence r/t use of laxatives a.e.b. inability to control passage of stool

· Risk for Deficient Fluid Volume r/t medically restricted intake (NPO for two days awaiting procedure)

· Imbalanced Nutrition: less than body requirements (NPO plus impaired digestion due to obstruction of bile flow)

I know that I have to do the "related to" and "as evidenced by", but first I am unsure which of these to use (I only need 4) and which are priority!

Any advice?

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Specializes in Pediatric Hematology/Oncology RN.

I would go with acute pain, risk for fluid volume deficit, risk for infection and a psychosocial nursing diagnosis maybe acute confusion

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@Nurse.KelseyThanks so much! In that order?

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Specializes in Pediatric Hematology/Oncology RN.

Actual diagnoses are always first - acute pain.

Then the go in order of importance.... so think risk for fluid volum deficit or risk for infection.... I would go with infection first...

then usually psychosocial is last

1. Acute Pain

2. Risk for infection

3. Risk for fluild volume deficit

4. Acute Confusion

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The first 3 I am clear on the related factors and appropriate interventions.

What about Acute Confusion? Also how do I know if the disorientation is the patient's baseline? She is 90 years old...

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Specializes in Pediatric Hematology/Oncology RN.

@devvie I guess that depends on if there is more information in the case study that can confirm that for you. Theres also the nursing diagnosis Impaired Memory.

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Sorry I keep asking but we were never taught how to do Nursing Diagnoses/Care plan in class....

What can be supporting data for Risk for Infection? I can't do low WBC count because her levels are high, I guess because the gallbladder is inflamed.

So is there anything other than the fact that there is a surgical site? And that she isn't capable of taking care of the site, maybe?

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Specializes in Pediatric Hematology/Oncology RN.

Well you are right in your rationale for surgical site. Any open wound can be a risk for infection. Any surgery has a risk for infection

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On 9/29/2019 at 11:03 AM, Devvie said:

I need to do a nursing care plan for the first time. My patient is a 90 year old female, disoriented, in the hospital for gallstones.

The nursing diagnoses I cam up with are:

· Acute Pain r/t to gallstones as evidenced by pain of 6 on 0-10 scale and guarding

· Impaired Tissue Integrity r/t altered circulation a.e.b. pressure ulcer stage 1

· Risk for Infection r/t surgical site

· Bowel Incontinence r/t use of laxatives a.e.b. inability to control passage of stool

· Risk for Deficient Fluid Volume r/t medically restricted intake (NPO for two days awaiting procedure)

· Imbalanced Nutrition: less than body requirements (NPO plus impaired digestion due to obstruction of bile flow)

I know that I have to do the "related to" and "as evidenced by", but first I am unsure which of these to use (I only need 4) and which are priority!

Any advice?

I've been out of school for a while, so this may be all wrong but I'm feeling chatty...

Hospitalized pre-op patients get IV fluids. I would not use "risk for fluid volume deficit" because of NPO status.
I would also avoid "imbalanced nutrition", as that would be more of a long term thing. I see people use things like that when a patient is NPO for six hours. We would all have "imbalanced nutrition" between lunch and dinner if that were the case. Others obviously have differing opinions ...and they may be right.

And of course, if she's 90 and chronically ill, she may very well have issues with nutrition ...I just wouldn't ride it all on one acute problem.

"Bowel Incontinence r/t use of laxatives a.e.b. inability to control passage of stool"

I'm not sure what to make of this one either? Anyone? Is it a problem if you're actually inducing it?

Acute pain is good.

Risk for infection is good. More infection is possible, even with existing infection. The surgical site is at risk, and the patient has a stage I pressure ulcer that could progress, too.

Risk for fall or injury is probably a good one. She's elderly, disoriented, in a strange place, and in pain.

Impaired mobility might also work if she's normally more functional.


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Anyone else know about the Bowel Incontinence? My friend suggested it but we're both new at this

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