nursing care plan help

Del07 · Apr 28, 2011

Hello!
I have a care plan assignment due, where we need to have three diagnosis, and I'm stuck on the very last one.
pt is a post op from an exploratory laproscopy, which resulted in a sigmoid colectomy with injury to L ureter. Pt had a SBO. Pt has a history of HTN, asthma, and diverticulitis.
The two care plans I've already done are:
risk for infection RT abdominal surgery, presence of IV and Foley.
Pain RT abdominal surgery.
I'm having trouble coming up with one more.
Pt currently has NPO, and is receiving IV nutrition. Pt has a Foley in and an NG to intermittent suction. for pain, pt has an epidural.
I was thinking of Risk of fluid/electrolyte imbalance RT NG tube with suction; or activity intolerance RT acute pain secondary to abdominal surgery, but I'm not sure how to go about either of them.
Thank you in advance!

I think you should go with Risk of fluid and Electrolyte Imbalance. You wouldnt want to go with acute pain for ur third because it will come out repeating itself because you already chose pain for your second diagnosis.

alliebeans, NP · Apr 28, 2011

I'm just kind of confused as to how to write that one up. I found examples for the other ones in my books, but the teachers aren't too descriptive on how we should really write this up and I'm super stuck on that one. I really appreciate your reply so quickly.

Del07 · Apr 28, 2011

I'm just kind of confused as to how to write that one up. I found examples for the other ones in my books, but the teachers aren't too descriptive on how we should really write this up and I'm super stuck on that one. I really appreciate your reply so quickly.

We actually have a careplan book and it works wonders. Let me know what u need help with and I will look it up for u. It has expected outcomes rationales implementations and so on

bhanson · Apr 28, 2011

Hello!
I have a care plan assignment due, where we need to have three diagnosis, and I'm stuck on the very last one.
pt is a post op from an exploratory laproscopy, which resulted in a sigmoid colectomy with injury to L ureter. Pt had a SBO. Pt has a history of HTN, asthma, and diverticulitis.
The two care plans I've already done are:
risk for infection RT abdominal surgery, presence of IV and Foley.
Pain RT abdominal surgery.
I'm having trouble coming up with one more.
Pt currently has NPO, and is receiving IV nutrition. Pt has a Foley in and an NG to intermittent suction. for pain, pt has an epidural.
I was thinking of Risk of fluid/electrolyte imbalance RT NG tube with suction; or activity intolerance RT acute pain secondary to abdominal surgery, but I'm not sure how to go about either of them.
Thank you in advance!

Pain is not a nursing diagnosis. You'll probably want to use Acute Pain.

How does abdominal surgery increase the risk for infection? How does an IV increase the risk of infection? How does a foley increase the risk of infection? None of those are risk factors for "Risk for Infection." You need to explain the specific mechanism that cause the client to be at an increased risk for infection. The definition of risk for infection is "At increased risk for being invaded by pathogenic organisms." Think along the lines of the chain of infection and explain why alterations to various stages would increase the risk for the client.

Acute pain is also not a defining characteristic of activity intolerance. Activity tolerence is "Insufficient physiological or psychological energy to endure or complete required or desired daily activities." Example characteristics are changes in blood pressure or heart rate on activity, discomfort or dyspnea on exertion, or a verbal report of fatigue or weakness.

You really need to make sure your etiology and signs and symptoms are appropriate for your diagnostic label.

alliebeans, NP · Apr 28, 2011

@Del

Thank you so much. I'm going to be working on the assignment again tonight and will probably post what I need help with while doing that. Also, what book are you using? Or is it something provided to you by your school? I know we're using a Nursing diagnosis Handbook by Carpenito-Moyet.

@bh

I'm still writing the report, and the risk for infection was written out by my teacher for me as a guideline mostly, so I didn't actually do all the work on that one. The teacher told me exactly how to re-write and re-word everything on that. And I found a care plan for pain in my book. So Acute pain RT abdominal surgery is ok, as my Nursing Diagnosis handbook also has that listed.