Care Plan-Too Many Mysteries

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I'm so stumped on my current care plan. We are supposed to analzye the labs, and write up some details. Some are quite clear...while others are not making sense. Maybe somebody with more experience can help me solve this mystery.

Pt history is Thyroidectomy/Hypothyroidism; Hernia Repair '05, Kidney Infection w/blockage & Stent Placement; Peptic Ulcer Disease; Diverticulosis w/Diminutive Polyps.

Pt was admitted with- 1 week abdominal pain, nausea,vomitting, blood in stool, no appetite. Current visit EGD shows duodenal & pyloric ulcers.

Pt normally takes aspirin & synthroid, but has been stopped for 2 days.

Pt is currently receiving only Protonix IV, and had received a few doses of Zofran and Hydromorphone upon admittance.

In looking at the labs, it makes sense that RBCs are low, Hgb is low, MCV is high, and MCHC is low (I believe from blood loss/anemia). It also makes sense that BUN/Creatinine are both high (since client is has low appetite & not eating much).

What is not making sense is the PTT of 21 (why aren't they giving her anything & why does she have bathroom priveleges?) Also...in her urine is protein-10, ketones-10, WBC-53, Epithelial-4, Bacteria-small??? Is this just considered urinary tract infection? If so...why wouldn't she be on antibiotics for it?

If anybody sees any "loose ends" that I'm missing...or if I'm "way off", I would appreciate ANY insight.

Thanks in advance!!!

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

a lab reference will have the reasons for increased and decreased levels of the various lab tests. some of the online lab test sites will also do that if you do not have a lab reference book. the links to them are listed here:

why wouldn't the patient be on antibiotics for "small" bacteria in her urine? on that same list of links above, look up utis in the merck manual and on some of the other sites such as webmd, medicinenet and especially family practice notebook (use the search box and type the complete name out) and their treatment.

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So, after researching a bit more, I've determined the probable reason for the ketones-10 is starvation/calorie deprivation from lack of appetite;small bacteria isn't really unusual; epithelial-4 may just be some contamination, although may be signs of nephrotic syndrome or tubular degeneration; protein-10 may be linked to nephrotic syndrome, but for a single specimin seems to be just slightly above the normal range, and WBC-52 is definitely high...and I've not found anything other than it is indicative of urinary tract/lady partsl infection.

After further research I discovered that 1.8-Creatinine and 25-BUN are most likely indicative of kidney malfunction.

I'm not sure about the PTT, and although it was noted as (low) on the lab report....could this possibly be because she takes aspirin daily? Maybe this isn't a detail I should focus on in my plan of care. Does it sound like I could focus on the bleeding ulcers, and the probable kidney issues? Any ideas on nursing diagnosis for the kidney issues would be appreciated....as well as opinions/ideas as to my perception of things thus far.

Thanks again!!!

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Specializes in Med/Surg.
So, after researching a bit more, I've determined the probable reason for the ketones-10 is starvation/calorie deprivation from lack of appetite;small bacteria isn't really unusual; epithelial-4 may just be some contamination, although may be signs of nephrotic syndrome or tubular degeneration; protein-10 may be linked to nephrotic syndrome, but for a single specimin seems to be just slightly above the normal range, and WBC-52 is definitely high...and I've not found anything other than it is indicative of urinary tract/lady partsl infection.

After further research I discovered that 1.8-Creatinine and 25-BUN are most likely indicative of kidney malfunction.

I'm not sure about the PTT, and although it was noted as (low) on the lab report....could this possibly be because she takes aspirin daily? Maybe this isn't a detail I should focus on in my plan of care. Does it sound like I could focus on the bleeding ulcers, and the probable kidney issues? Any ideas on nursing diagnosis for the kidney issues would be appreciated....as well as opinions/ideas as to my perception of things thus far.

Thanks again!!!

Not sure how much I can add...

The creat is not elevated due to intake (for that you'll see low total proteins and albumin levels), it's due to the kidney blockage/stent placement most likely. Creat is a much better indicator of kidney function than BUN. However, dehydration CAN elevate a creat, but I wouldn't think to that degree.

The PTT could be due to the aspirin, even if it's stopped, it would take time to get out of the system. He also could just have a bleeding disorder of some sort....*thinking, thinking*...if it's LOW (I had to go back and look, sorry, worked 13+ hours tonite!) he may have a clotting disorder and needs to be on something for it. May be unrelated to anything else.

I would say the high WBC in the urine would indicate infection. If she's not on antibiotics, it may have been an oversight, and you should ask if the doc is aware of it and wants antibiotics.

Hope this made sense and helped.

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

ever hear of a detective that just looks at someone at the scene of a crime and says, "he looks good for it. arrest him." you'd be outraged. why? he needs proof to back up his claim, not a hunch. even monk, who will often declare early in the program who the killer is, spends the rest of the hour entertaining the audience with proving how the killer did the murder.

evidence is always required to back up any decisions that we make in nursing. we accomplish this with the nursing process which is a wonderful tool that can serve you well in many capacities. care planning is only one of them. the nursing process is a 5-step problem solving process. here is how it works for care planning.

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

use the nursing process to help organize yourself as you write this care plan and begin. . .

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - you need to look up information about these diseases, conditions and treatments. why were these drugs given to the patient? why was the patient taking aspirin and how may it have contributed to any of her current problems (look at side effects and complications of treatments and diseases). in other words, get inside the doctor's head as well because he is assessing and developing a plan of action just as you are about to do.

  • medical diseases/conditions
    • thyroidectomy/hypothyroidism
    • kidney infection w/blockage & stent placement
    • peptic ulcer disease
    • diverticulosis w/diminutive polyps

    [*]medical treatments

    • hernia repair '05
    • egd shows duodenal & pyloric ulcers
    • aspirin & synthyroid
    • protonix iv
    • zofran and hydromorphone upon admittance

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - your evidence (clues) that the patient has problems. our job is to define them in terms of nursing problems.

  • nausea
  • vomiting
  • blood in stool
  • no appetite
  • rbcs are low
  • hgb is low
  • mcv is high
  • mchc is low
  • bun/creatinine are both high (most likely indicative of kidney malfunction)
  • 1 week abdominal pain

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -

deficient fluid volume r/t active fluid volume losses aeb vomiting, blood in stool, low rbcs, low hgb, high bun/creatinine, high mcv, low mchc, elevated urine protein of 10 and slightly elevated epithelial cells in urine

imbalanced nutrition: less than body requirements r/t inability to eat aeb nausea, no appetite, and ketones in urine

acute pain r/t irritated gastric and duodenal mucosa aeb abdominal pain

risk for infection r/t elevated white cell count and small amount of bacteria in urine

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