Need Help with care plan


I had a post op patient on 3/29/2011 with recto vesicle fistula with urinary diversion, he also had colon cancer in 2009. His pain level was at 0. I was thinking that my 3 care plans should be risk for infection, risk for pain, and I don't know...HELP.

Specializes in Medical Surgical/Addiction/Mental Health.

Your patient doesn’t have any pain? Excellent pain management! What about activity? Is he able to get up and go to the bathroom? If so, is it a chore for him? Is you patient experiencing any anxiety by being in the hospital? Is you patient coping well with his current situation? Is your patient chronically fatigued? Does he have any fear relating to his condition? How about fluid volume? Gas exchange good? How is his nutrition? Mobility? Skin? Tissue perfusion? Urinary elimination?

I hope some of these questions will help direct you.

Good luck.


12 Posts

My teacher use to hate when we used risk for pain. She said it was too easy for us to do. LOL But i suggest thinking about risk for impaired skin integrity since the client has a diversion device. And if the patient needs to be taught any post op skills you can also think about Deficient knowledge.

Specializes in Infusion, Med/Surg/Tele, Outpatient. Has 15 years experience.

Your care plan is derived from data you collected during your assessment. What assessment findings do you have of this patient that show a problem. "0/10" pain is not a problem! Risk for infection is about all I'd let you have for "risk for" as UTI in this pt would be BAD BAD.

NANDA dx r/t intervenable issues AEB documented problems! (sorry, pet peeves.)

Impaired gas exchange r/t flash pulmonary edema AEB new onset SOB, new crackles heard in lungs, pt anxious and agitated, sats 84%.

Interventions - call RRT (prevent further harm, get expert help); apply oxygen by face mask; call MD - anticpated orders for lasix, oxygen, chest xray, ekg, etc. etc. etc. Expected outcome - pt to maintain oxygen sats > 92%.


17 Posts

Impaired Urinary Elimination

Risk for Injury

Activity Intolerance