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I could use some help...my final care plan is due tomorrow from last nights patient. I need diagnoses for each system, as well as 4 priority diagnoses for her problems...I have a few in mind here, and am working on it..but this thing is worth 150 points out of 300 needed to pass! 49 yr old female: Admitted for acute abd. pain, nausea, vomiting. Diagnostic laparoscopy performed on day 2 of hospitalization for partial bowel obstruction, lysis of adhesions...5 small incisions in abd. Surgical hx includes: 2006 gastric bypass Spring 2008:Hernia repair (5 areas) and cholecystectomy at that time. Summer 2008: Appendectomy Medical Hx: Hypertension, GERD, Migraine headaches, Depression. States she was told she had a slight "heart murmur"-but does not require SBE prophylaxis...nothing listed in her chart about this. Weight loss of 85 lbs since gastric bypass surgery, 6 lb weight loss since hospitalization (4 days) states she follows the Southbeach diet at home. Meds include Protonix, Zoloft, Norvasc, Multi vitamins at home. (hospitalization includes zofran, dilaudid q2h prn, heparin therapy) She requires and requests pain meds every 2 hours... Foley d/c'd today, voiding VS BP:135-69, Pulse: 64, Resp: 20, normal, lungs clear, Pulse ox 95% RA. She smokes 4-6 cig./day Labs:Abnormals only RBC: 3.75 HGB: 10.4 HCT: 31.0 RdW: 15.8 PLATELET: 235 NEUT ABS: 6.9 LYMPH ABS:0.8 NEUT: 87.4 LYMPH: 10.0 Fasting Glucose: 132--only time it was elevated She was A&O xs 3--pain averaged 7-8, and after Dilaudid, 5 at best. Ambulating, voiding, BM day 2 post op nd: Acute Pain? Nutrition less than requirements r/t bypass, Body image disturbed? Readiness for enhanced nutrition? Anxiety? R/f unstable glucose? R/f Infection r/t incisions? Does smoking come into play here for lungs? what about ND's for systems w/ no problems! Interruption in family process? (married, 1 child) ugh! I gotta get working on this...will be good to see your responses and if I'm on the right track!

I really appreciate the time you've taken to reply to my request. I wish I could send you a box of chocolate! I have a bit more information...Some of the information is missing, and even my instructor could not find it in the chart. The pressure ulcer was about 3 cm in diameter, slight drainage...serosanguaneous Although the patient wasn't talking by the time I got there, she would grimace and moan slightly when positioned on her back, so we opted to move her from side to side..however, the nurse said she had alot of pain in her left hip, verbalized by the patient earlier in the day. Xray did not show any fracture. The darvocet was prescribed for the complaints of pain from lying on her back (?pressure ulcer?) and her hip. The only entry in the chart regarding he ERCP was that she had Obstructive Jaundice. The "severe diarrhea"--that was my description. In thinking about it, it was watery stools, but 4 to 5 per day. We could not find an indication for the Flagyl. her lung sounds were clear, but her very shallow breathing made it difficult to evaluate completely as she couldn't respond with deep breathing. Did I miss something here? No ABG's were drawn - her respirations went down quickly, and the nurse got an order for the rebreather mask asap---before that she was on 3 liters / nasal cannula (Not sure if I mentioned that) Her labs were: WBC 8.9 RBC 3.93 (L) Hgb 13.4, Hct 39.5, Platelet count 127 (L) Na 141, K 3.7 BUN 66 (H) CREATNINE 3.1 (H) GFR i 15 (less than 15 is kidney failure, right?) These were drawn that morning. The staff nurse told me that when she was talking earlier in the day, she told her "I think I'm dying-I hope my family understands-I'm tired" I have worked up impaired gas exchange and ineffective breathing pattern so far, and started on pain. I just don't know if I have enough based on her statement of death to consider it death anxiety--she was definitely anxious/restless, but I would be too if I couldn't get enough O2! Just want to say that I think you are a saint. I've printed and spent some more time on this site, including the links you suggested. They too were helpful. Thanks again for your time.

2nd semester student here...I need some help...My patient last night was a 98 yr old female w/admitting diagnoses of Jaundice. She also had a small stage 2 pressure ulcer-sacral. Her past history included multiple falls, Hypertension, CHF, Renal Failure, Osteoporosis. Currently suffering from severe diarrhea, and also had an ERCP done on 4/17--"multiple stones, stent placed" The only medications listed was Flagyl, 250 mg at 16:00 and 22:00, Darvocet bid and ASA 81 mg / day she was currently on 3 liters of O2 nasal cannula. When I initially went to her room, I was told that she had been moved to a room closer to the nurses station as she was failing quickly. She was not responding other than opening her eyes once in awhile, when I spoke to her and was restless, but earlier in the day she I was told by the nurse that she was having pretty normal conversations with her. Pulse was 93, respirations: 36 BP 102/82 pulse ox 73. She was put on 15 liters O2 non rebreather mask. she went further downhill... Resp. 42 & shallow, BP 60/36 pulse 90,and within 2 hours her care was changed to "comfort measures" --(had a DNR)--all meds d/c'd, morphine 1-2 mg q 2 hours, IV. They didn't think she would make It through the night. I'm attempting to start a careplan to turn in to my instructor. (boy, its tough to not get emotional!) I admit to having problems prioritizing (as indicated by my last request for help!) but where do I start? Do I begin with the information I was given, and then progress to "Death anxiety?" I need 4 Nursing Diagnoses... I have several in mind, but this patient was dying. I think her pain and making her as comfortable as possible is most important, yet working up 3 assessments, 3 interventions and 3 teachings on FOUR diagnoses has me in a quandry. I'm starting to work on this now, and will check back for some advice if someone can help. I really appreciate it!

Daytonite, Thank you so much for your explanation. I'm still trying to develope that critical thinking brain--you are awesome--this helps me put things in perspective!

I've been told that a "risk for" diagnosis should never be your #1 priority diagnosis. What about a patient who is bleeding (miscarriage?) Is it then acceptable to use risk for fluid volume deficit r/t bleeding due to miscarriage?