Need help with first Med-Surg Care Plan Please

mfatony · Nov 6, 2009

you could use risk for falls due to her being 78 maybe. I would use nausea as a dx too. Since she has rectal cancer to me that would be chronic pain not acute. Just remember you have to use airway first when prioritizing...just a couple hints..hope they help

itsmejuli · Nov 6, 2009

My first thoughts are what is her nutritional status and the condition of her heart.

Forever Sunshine, ASN, RN · Nov 6, 2009

Greetings everyone,
I am writing my first Med-Surg care plan. I've written 2 other care plans that I got As on, so I thought this would go well, but I am stuck. My patient is a 78 yr. old woman, admitted with nausea, vomiting, abd. pain, rectal cancer. She has a left portacath. Past Hx: Thyroid surgery, appendectomy and failure to thrive. She has bilateral edema in lower extremities. She is perioperative DVT prophylaxis. Procedures include an esophagogastroduodenscopy. Her labs are: K 4.4, RBC 2.65, HGB 8.9, HCT 25.8, WBC 5.3, Albumin 1.1, Calcium 6.9, Plt 261.
So far I am thinking Risk for infection,Acute pain, Risk for injury related to anticogulant therapy, Increased isotonic fluid retention as evidenced by edema related to low protein intake.
What do you guys think? I would appreciate any wisdom that you can offer. Also if these sound good, which would be your priority?

The fluid retention dx is good. I would also add Imbalanced Nutritional Status: Less than Body Requirements. Her RBCS are low..hematocrit is low.. albumin is low.. calcium is low. Nutrition is a focus here.

Queen yaya · Nov 6, 2009

Thanks for responding. I was thinking that her pain was chronic related to rectal cancer, but after assessing her and reading her chart, it seems that her pain was not related to the cancer. I could find nothing in her chart with regard to her heart, other than her labs. Pretty much everything is low. I am thinking that there is a better r/t for her edema. She was placed on a full liquid diet upon admission (11/2). I keep thinking edema=heart. Maybe I am overthinking. :specs:

Queen yaya · Nov 8, 2009

Ok, this is what I came up with.

1. Deficient Fluid Volume R/T protein and albumin loss AEB bilateral pitting edema of lower extremities and hand edema.

2. Risk for injury related to altered clotting factors.

3. Acute pain R/T gastrointestinal distress AEB patient reporting pain of 9/10 upon admission.

I chose these as my highest priority nursing diagnosis. I think I am addressing her nutrition in the first . I'm not sure though if pain trumps risk for infection. I am thinking that an actual trumps a risk. Is that correct? Thanks for your eyes. :specs:

mfatony · Nov 8, 2009

My instructors always told us that you can't have a risk as your first diagnoses.. and pain would be over that one anyway

Forever Sunshine, ASN, RN · Nov 8, 2009

Ok, this is what I came up with.
1. Deficient Fluid Volume R/T protein and albumin loss AEB bilateral pitting edema of lower extremities and hand edema.
2. Risk for injury related to altered clotting factors.
3. Acute pain R/T gastrointestinal distress AEB patient reporting pain of 9/10 upon admission.
I chose these as my highest priority nursing diagnosis. I think I am addressing her nutrition in the first . I'm not sure though if pain trumps risk for infection. I am thinking that an actual trumps a risk. Is that correct? Thanks for your eyes.

I would address fluid volume as first. Nutrition I'd put second and then pain after that. Its been about 4 months since I've done my last care plan so I'm kinda rusty with this. It's helped jogged my memory though because I am taking NCLEX-PN on tuesday.

Queen yaya · Nov 14, 2009

Thanks everyone for your assistance. I turned it in and as expected she picked it apart :wink2:. Well not too badly, even though I mentioned the patient's nausea in my report, I neglected to include it in my diagnosis and then I did interventions for it with relation to my first diagnosis. In my head I was thinking that her low levels of protein resulting from her not eating due to nausea...well that's what I get for keeping stuff in my head. Oh well on to the next one.