nursing plan help

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Hello everyone, I am looking for help with my nursing care plan, my diagnsis is risk for skin impairment r/t immobility. The only assessmnet data that I have is that the client is immobile, orthostatic dyspnea, and is relatively weak. Thsi is my first year in nursing school and I haven't really gotten the hang of these care plans yet. :saint:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you cannot have any actual abnormal assessment data (symptoms) for this diagnosis (problem) which is what you need to support an actual nursing problem because it does not exist. risk for skin impairment would be a potential, or anticipatory, nursing diagnosis. a potential nursing diagnosis is done for a nursing problem that you "think" might happen based on what you know about the patient. i am assuming that your aim here is that the patient may develop a pressure ulcer and that is what you plan to prevent. there are only two types of nursing interventions that you can have for potential nursing problems:

  1. strategies to prevent the problem from happening in the first place
  2. and, monitoring for signs and symptoms of the problem (so you have to be specific about what problem you are attempting to prevent

these types of nursing diagnoses, as a general rule, do not have the same priority as actual nursing problems. actual problems must be attended to first.

you have two actual symptoms that you need to address and find nursing diagnoses for: orthostatic dyspnea and weakness.

please read the information about writing care plans on this sticky thread before you do any more work on this care plan:

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Hey everyone,

I am having a hard time finding a ND for my pt. It has to tie in with a liver/hepatic focus.

Pt male 74yo in ICU for post op pancreatectomy (yea the whole thing...apparently they can do that now) and whipple procedure. He had a tumor on his pancreas blocking the bile duct. He previously had a stent placed so he does not have jaundice now (which I would have used a ND on that if he did).

He is diabetic and pretty uncontrolled. Now he will need insulin injections all the time. Malnourished from poor appetite, upset stomach, wt loss for 2 months before this procedure.

On CT liver or spleen are not enlarged.

T-tube is draining well.

hgb/hct are low but he was transfused with 4 units and now are close to normal.

Albumin/protein low obviously.

AST high

ALT normal.

BUN 30

Cr 1.9

Also had an acute MI first night post op.

I dont know how to tie this into liver.........HELP PLEASE!!!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

read the information on writing care plans in the sticky thread link that i posted above. nursing diagnoses are based upon the responses the patient has to the medical diseases/conditions they are experiencing. that is something that you just cannot change. every nursing diagnosis has a defined set of symptoms and the patient must have at least one or more of them in order to be classified with any particular diagnosis--part of the rules of diagnosing. however, the "tie in" you are looking for to any liver disease is going to be with knowing the pathophysiology of what is going on (why was the pancreatectomy and whipple done. was is the metastasis? knowing the pathophysiology of cancer.) some of the related factors (etiology, r/t part) for your nursing diagnostic statements will reflect that "tie in".

i read through your post and the symptoms you did post. i could help but notice that you mention that this patient had an mi yet he has no cardiac symptoms at all with everything going on? atherosclerosis is a complication of diabetes. my first thoughts were that this was kind of strange. it is quite possible that his primary cancer may metastasize to his heart or lungs. i had a cousin who had a rare primary pancreatic cancer and had a pancreatectomy. after all his surgery, chemo, and radiation, he still had mets to his heart and had several cadiocentesis procedures due to infiltrates that accumulated in the pericardial space (he was only 40 years old). with diabetes, an mi, cancer in the gi tract and a post-op whipple, this is a complex patient who will end up having a complicated care plan.

pancreatectomy and whipple procedures have been done for some years.

http://www.surgeryencyclopedia.com/la-pa/pancreatectomy.html

you can find all kinds of information about all of the different cancers on the website of the national cancer institute (http://www.cancer.gov/).

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Those links were interesting Daytonite! I still dont know what to do for a ND though. He is doing great post op! Good for him....not so good for me. His acute MI was not symptomatic except for a 'pause' on EKG so they drew a cardiac panel and the levels were through the roof. He has a t-tube that is draining well! Nothing about mets.

Is there something I can say like a risk for infection r/t t-tube?

Can that cause an infection in the liver?

Anything about absorbtion since the bile is draining into tube and

not intestine?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

read the information on

actual nursing problems (what become your nursing diagnoses) are always based upon the abnormal assessment data you picked up during your assessment of the patient. they form the basis for your nursing diagnoses. you can care plan for anticipated or potential nursing problems if you like (that would be the risk for infection r/t presence of invasive drain which would be the t-tube) but these types of problems are of a lower priority and you can only have nursing interventions to prevent the targeted problem from occurring and monitoring/reporting signs/symptoms of it. the bile is draining into the t-tube for the time being because of swelling in the operative area (you need to read the pathophysiology of tissue trauma and how the inflammation response is evoked causing swelling in the tissues). the t-tube is placed so that bile which is continually produced doesn't build up inside the liver or gallbladder. the bile has to be removed. swelling of the tissues causes obstruction and closure of the route to where ever the bile is now going to be shunted to since the surgery and needs to be kept patent until the swelling resolves. as the swelling subsides, the t-tube drainage will lessen, the bile will start going where it is supposed to go in the body, and eventually the tube will be removed. until then, the patient's stools will be clay colored depending on how much bile is able to bypass the t-tube and continue on down into the lower intestinal tract. monitoring the color of the patient's stools will tell you a little of how some of the internal healing is going.

do you have a pathophysiology book? a lot of your questions would be explained in one. bun, or urea, is an end product of protein metabolism in the liver. the bun is directly related to the metabolic function of the liver as well as the excretory function of the kidneys. there is one of your links to the liver. ast, aspartate aminotransferase, or sgot, is elevated when someone has an mi but also when there is some kind of inflammation or disease going on in the liver and with anemia. there's another link to the liver. however, the low protein and albumin levels link you to the liver as well because that is where these substances are produced.

the patient's symptom's you listed:

  • poor appetite
  • upset stomach (nausea?)
  • weight loss of ?? in past 2 months
  • low albumin and protein levels
  • high ast (aspartate aminotransferase, sgot)
  • bun 30
  • creatinine 1.9 - related to renal function only

you use those to match them with defining characteristics of nursing diagnoses that apply.

imbalanced nutrition: less than body requirements r/t malignancy of pancreas and inflammation of liver and other gi structures aeb weight loss of xx pounds over the past two months, upset stomach, poor appetite, low protein and albumin levels.

i added this one even though you show no data to support it--find some! knowledge deficit, home management of surgical and disease induced diabetes r/t lack of facts aeb [need patient data]

risk for injury r/t presence of invasive drain

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read the information on

actual nursing problems (what become your nursing diagnoses) are always based upon the abnormal assessment data you picked up during your assessment of the patient. they form the basis for your nursing diagnoses. you can care plan for anticipated or potential nursing problems if you like (that would be the risk for infection r/t presence of invasive drain which would be the t-tube) but these types of problems are of a lower priority and you can only have nursing interventions to prevent the targeted problem from occurring and monitoring/reporting signs/symptoms of it. the bile is draining into the t-tube for the time being because of swelling in the operative area (you need to read the pathophysiology of tissue trauma and how the inflammation response is evoked causing swelling in the tissues). the t-tube is placed so that bile which is continually produced doesn't build up inside the liver or gallbladder. the bile has to be removed. swelling of the tissues causes obstruction and closure of the route to where ever the bile is now going to be shunted to since the surgery and needs to be kept patent until the swelling resolves. as the swelling subsides, the t-tube drainage will lessen, the bile will start going where it is supposed to go in the body, and eventually the tube will be removed. until then, the patient's stools will be clay colored depending on how much bile is able to bypass the t-tube and continue on down into the lower intestinal tract. monitoring the color of the patient's stools will tell you a little of how some of the internal healing is going.

do you have a pathophysiology book? a lot of your questions would be explained in one. bun, or urea, is an end product of protein metabolism in the liver. the bun is directly related to the metabolic function of the liver as well as the excretory function of the kidneys. there is one of your links to the liver. ast, aspartate aminotransferase, or sgot, is elevated when someone has an mi but also when there is some kind of inflammation or disease going on in the liver and with anemia. there's another link to the liver. however, the low protein and albumin levels link you to the liver as well because that is where these substances are produced.

the patient's symptom's you listed:

  • poor appetite
  • upset stomach (nausea?)
  • weight loss of ?? in past 2 months
  • low albumin and protein levels
  • high ast (aspartate aminotransferase, sgot)
  • bun 30
  • creatinine 1.9 - related to renal function only

you use those to match them with defining characteristics of nursing diagnoses that apply.

imbalanced nutrition: less than body requirements r/t malignancy of pancreas and inflammation of liver and other gi structures aeb weight loss of xx pounds over the past two months, upset stomach, poor appetite, low protein and albumin levels.

i added this one even though you show no data to support it--find some! knowledge deficit, home management of surgical and disease induced diabetes r/t lack of facts aeb [need patient data]

risk for injury r/t presence of invasive drain

your post on this topic is so helpful. thanks so much for taking the time to post. i am a 3rd semester student just over 1/3 of the way done with my 3rd semester of a 4 semester adn program. i am learning iv's and saw that you are super at iv fluids any pointers on knowing what fluids to use for what? i'm a slow learner--more hands on than anything. thanks so much for your help!

tabblet

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