HELP! Nursing Dx for care plan...

[wannabeRN2010]

I am working on my FIRST care plan (which is due tomorrow) and cannot decide on a nursing diagnosis. My pt was admitted for a GI bleed and now has a NG tube inserted for suction and has been NPO for three days.

I was going to use risk for fluid and electrolyte imbalance, but my nursing dx book says not to use that for a pt with NPO status. Then maybe impaired comfort, but no longer an acceptable dx. He has no pain, is totally ambulatory, family visits him often... I am stuck!!

Any ideas would be more than appreciated...

[Daytonite, BSN, RN]

your nursing diagnosis book is only a guideline and not to be taken as rules set in stone. you must consider the patient's circumstances and symptoms. the book doesn't have that information because each patient is unique.

he would be deficient fluid volume because of the gi bleeding, not because of the presence of the ng tube and being npo. deficient fluid volume is defined as "decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium." (page 90, nanda-i nursing diagnoses: definitions & classification 2007-2008) blood is a fluid of the intravascular space and if you have lab evidence that proves it is low (decreased hbg and hct) as well as any physical signs and symptoms, then you have deficient fluid volume.

the ng tube is a foreign body. the body's response to its presence is to initiate the inflammation response: redness, heat, swelling, pain. you can't see these things happening because the tube in the nostrils, back of the throat and going down the esophagus. you are thinking of impaired comfort because of the presence of the tube being irritating and producing excessive mucous, right? this is only part of the inflammation response. believe me, the rest is going on as well. patients with these tubes get sore throats and sore nostrils. now, if he actually has these, then he has acute pain. the pain is a result of the swollen tissues pushing on pain receptor nerves and setting them off. if that hasn't occurred yet, then he is at risk for injury (sore throat and nostrils due to presence of foreign body).

is he having tests? then there is deficient knowledge, diagnostic procedures. that probably wasn't in the care plan book for gi bleeding either.