Making a care plan

[Kevsab7]

So tomorrow is my first day of clinical at the hospital and they wanted us to do a care plan so I'm very new at all this...Some help will be great.. I'm just having problems adjusting to this new way of thinking mindset. I got some nursing diagnosis not sure if they're in the right order or if there is more.. I want to learn and be guided in the right direction.

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."

The following labs were ordered and obtained in the Emergency Room (ER): CBC with diff, Chem 14, Blood C&S, Stools for O&P, Stool for C. Difficile, Stool C&S, U/A & UCx

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

The patient is admitted to the medical-surgical unit.

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. No bruises or lesions noted

Neuro: Alert, awake and oriented to person, place and time. PERRLA. EOM's sluggish

Neck: No JVD, No Bruits auscultated

Thorax: S1, S2 regular. Apical pulse 120 strong, regular. Respirations 30 equal chest rises, labored with slight use of accessory muscles

Abd: Flat, non-distended, 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. Upper and lower with full ROM's

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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Nursing Diagnoses in order of priority:

1) Nursing Dx-Risk for deficient fluid volumes related to excessive fluid output (or Excessive emesis?)

2) Nursing Dx-

4) Nursing Dx-Fatigue related to Poor physical condition

I just want to know so far if I'm on the right track... thanks for your time guys!

[happydrunkcat]

Her skin has a decreased turgor. So - Deficient fluid volume rt to active fluid volume loss as evidenced by 5 day history of intractable vomiting. (it's not a risk for anymore, it is already happened)

Another nd you can use: imbalanced nutrition, acute pain, impaired physical mobility

About Fatigue related to Poor physical condition - what are you going to write after "as evidenced by"? You can say something like "pt states she gets tired easily" or something like this.

Good luck!

[Kevsab7]

How about this? please any corrections or suggestions again would be grateful.

1-Deficient fluid volume related to active fluid volume loss as evidenced by 5 day history of intractable vomiting.

SHORT TERM GOALS:

- Patient will experience a decrease in vomiting within 24 hours.

- Patient will hold fluid volume

NURSING INTERVENTIONS:

- Obtain weights using same scale, same time of day, and same clothing, as much as possible.

- Educate my patient on normal fluid intake per day is 2200 to 2700 mL.

2- Imbalanced Nutrition: Less then body requirements related to inability to digest foods evidenced by over the past 2 days, she has had 5 liquid stools per day and can not tolerate a regular diet.

SHORT TERM GOALS:

- Patient will have balanced intake and output in 24 - 48 hours

- Patient will record their intake and output

NURSING INTERVENTIONS:

- Monitor nutrition intake

- Consult a Dietian

3-Acute pain related to poor posture evidenced by she ambulates with walker

4- Fatigue related to poor physical condition as evidenced by patient states she gets tired easily.

5- Impaired physical mobility related to ?

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This was my first posting and I am very pleased and happy to know how accurate and quick people are with the a response...THANK YOU!

[happydrunkcat]

I just woke up.. And I'm not a morning person..sooooooo :))

"Patient will experience a decrease in vomiting within 24 hours." - and then how your interventions help this goal?

Obtain weight, imo, better for "pt will not loose weight during the hospital stay", or something like this. Then your intervention will go closer to your goal. For your goal... maybe, administer antiemetics before offering fluids, offer fluids ... say.. 15 ml every 5 minutes (small portions often vs big portions, which is more difficult to keep down),

"Educate my patient on normal fluid intake per day is 2200 to 2700 mL." - in my opinion, does not make sense, because she probably knows, she just can't.

Maybe "pt will maintain good skin turgor" or something like that will be better? then interventions i'd put check skin turgor, maintain IV at .. whatever rate it is should be maintained..

Second one - Diet: Clear liquid, advance as tolerated. So

- Monitor intake - good.

- Consult a Dietian - why? If She can not keep the liquid diet down? maybe better again - smaller portions more often? administer prescribed antiemetics 30 minutes prior to intake? or something else that will help her keep the food down.

Acute pain related to poor posture evidenced by she ambulates with walker - ok... aeb is "how do we know she has a "whatever we just put in ND"? For your case it is "how do we know she has a pain? Because she ambulates with walker? No. Because when we asked her she said “I ache all over ", and maybe, she even stated her pain level of 5 on a 0-10 scale.

You are getting it :) Good Luck!