Help in writing Nursing Care Plan.

Trauma Columnist · Nov 3, 2003

Self-care deficit R/T recent abdominal surgery as evidenced by generalized weakness and inability to perform own ADLs. You need to address pain too. Look in a good nursing diagnosis book.

memphispanda, RN · Nov 3, 2003

Ok...where to start..

First, the Altered Nutrition is fine, however your related to isn't. The TPN isn't the cause of the problem, the cause is that the pt is unable to tolerate ingested food for whatever reason. Your interventions would be to give the TPN as ordered and perhaps consult with the nutritionist. You could come up with several more probably.

You could also look at pain as a diagnosis for a post-op pt. That is an easy one as far as interventions go.

If she is totally dependent, you need to look at what problems that causes. One of the major ones is risk for impaired skin integrity. What do you do to prevent skin integrity problems?

EastCoast · Nov 3, 2003

Originally posted by Rosered48
:. I understand that her nutrition needs can' t be altered because of the ordered TPN.

This is not a correct assumption. Because a patient is recieving TPN it does not assure that caloric needs are met. In fact if a patient becomes septic or develops a wound it tends to require a higher calorie. Also, bear in mind that TPN itself may predispose you to a hyperglycemic state.

Secondly, fluid and electrolyte imbalance. If this patient has an NGT worry about all the depletion and alkalosis.

Third...ADL and whatnot. Patient if immobile is prone to atelectasis, PE, and skin breakdown.

Pain as mentioned.

The list can go on and on. Like someone said get a reliable book.