nursing diagnosis n care plan

[ksurette]

Choose 2 nursing diagnosis and develop a care plan utilizing the steps of the nursing process. Remember to set 2 realistic goals for the client and develop nursing interventions that could help meet these goals, as well as the rationale for the interventions.

Case study.

Mr. B has been assigned to your care for the day shift. Mr. B is a 78year old male client in the hospital who is medically discharged. He is waiting for homecare to be initiated. He has a below the knee amputation of the Rt. leg and has prostate cancer. As a result of the prostate cancer Mr. B is unable to void on his own and has a Foley catheter. He has been nauseated and vomiting as a result of the chemotherapy that he is receiving. He has been NPO for the past two days and has an IV of R/L infusing at 100 mls/ hr. Mr. B usually is able to perform his own care and is ambulatory with prosthesis, but because of his vomiting and resulting weakness he requires partial assistance with his bath. During his morning bath you notice yellowish drainage around the Foley catheter. No other findings were noted.

By midafternoon the client has been free of vomiting for 6 hours and is beginning to feel hungry. You consult with his Dr. and the doctor orders the IV to be discontinued and to start the client on clear fluids.

• Mr. B's vital signs for 1000 hours are B/P 110/70, Pulse 68, RR-18, and Temp. 37°C, oxygen saturation on room air is 98%.
  
• Mr. B's vital signs for 1400 hours are B/P 118/74, Pulse 70, RR-18, and Temp. 36.8°C, oxygen saturation on room air is 96%.
  
• The Dr. requested that the client be weighed. You did so and the client's weight is 70 Kg.
  
• Mr. B's intake for dinner : 250 mls apple juice, 250 mls 7-up, 500 mls water, 500mls clear soup broth and a bowl of jello.
  

MY ANSWERS SO FAR:

Nursing Care Plan:

Nursing Diagnosis: (4marks)

• Nausea related to effects of chemotherapy as evidence by patient reporting nausea and chemotherapy treatment for cancer.
  
• Unable to void on his own and has a Foley catheter having yellowish discharge
  

Nursing Goal(s): (4 marks- 2 goals)

Nausea will be reduced.

Catheter will be clear of discharge and with nausea cleared can be removed

Nursing Interventions and Rationale (8 marks)

• Clients feel more comfortable
  
• Balanced fluid status
  

• Adequate nutrient intake
  
• Give / teaching methods of distraction from the sensation of nausea eg using music, etc..
  
• Motivate clients to eat / drink a little but often.
  
• Keep the catheter environment clean and washing with soap and water at least twice a day
  

Evaluation: (4 marks)

[Double-Helix, BSN, RN]

Do you have specific questions?

Diagnoses:

Your second nursing diagnosis is not formatted correctly as a nursing diagnosis. You mention the inability to void but your interventions do not address re-establishing continence. Is this something you can expect to fix right away? What does the yellow discharge suggest? Is there a different nursing diagnosis that might be more appropriate and more realistically treated?

Goals:

How will you measure reduced nausea?

Why does this patient have a catheter? You stated "with nausea cleared can be removed." Is that really true? Is the nausea the reason he has a catheter? No, he has a catheter because he cannot void on his own (hint- he can't void on his own because his enlarged prostate is compressing the urethra, obstructing the flow of urine). Furthermore, the discharge is not what you should be most worried about. The discharge is a sign of something- what? Eliminating that 'what' is where your focus should be.

Interventions:

Balanced fluid status, adequate nutrition intake and improved comfort are all GOALS, not interventions. Interventions are what you will do to make those things happen.

Hint: Look up evidence based practice for reducing CAUTI. That should give you some good information to go on.

[ksurette]

thank you these are great suggestions!

[ksurette]

are these two better written out nursing diagnosis?

[TABLE]

[TR]

[TD]Displaying Nausea and vomiting (r/t) to effects of chemotherapy

[/TD]

[/TR]

[TR]

[TD]Notice yellowish drainage with foley catheter (r/t) prostate cancer

[/TD]

[/TR]

[/TABLE]

[cecile9155, BSN, RN]

Are you supposed to be using NANDA nursing diagnoses?

[Double-Helix, BSN, RN]

I suggest reviewing this link for a list of approved NANDA nursing diagnoses.

Your diagnosis needs to be written in this format:

Nursing diagnosis related to medical diagnoses or cause as evidenced by supporting clinical data.

The nursing diagnosis you choose needs to come from the list in the link I posted above.