Really need help with care plan for patient

[schantzy143]

help!!! i have a care plan due soon and since my instructor is not emailing me back and answering my questions, i could really use some help. my patient is 78 years old and diagnosed with gallstone pancreatitis. he is in a lot of pain, has inspiriatory and expiratory wheezes throughout his lungs, sob, his bun (42) and creatinine (4.25) levels are also really high which to me indicates acute renal failure. the patient is on 3lnc, xopenex aerosol treatments, dilaudid q4hrs, lasix, potassium chloride, zosyn, has elevated bilirubin, wbc, alt, ast, amylase, and lipase.he is on a clear liquid diet, is hr ranges from 99-110, occasional sinus tachy on telemetry, +1 edema lower extremities, productive cough with thick yellow sputum, firm &distended/obese abdomen, voided 400ml during 7 hours of clinical day, took in a little over 1000ml during that time, and had warm/dry skin. potassium, iron, albumin, sodium, calcium, hct, hgb, and rbc are all low. there is obviously a lot going on with this patient so i am having a hard time coming up with 5 diagnoses, 3 of which i have to work out. so far i have

• ineffective airway clearance related to increased mucous production as evidenced by sob, inspiratory and expiratory wheezes throughout lungs, pox 93% on 3lnc, productive cough with thick yellow sputum and xopenex aerosol treatments three times a day.
  
• acute pain related to obstruction and inflammation of the common bile duct, inflammation, edema, distention of the pancreas, and peritoneal irritation as evidenced by patient reporting a pain of 8 on a 1 to 10 scale, the need for dilaudid every 4 hours, pain and tenderness in ruq and back, and pain when coughing.
  
• excessive fluid volume related to renal insufficiency as evidenced by intake greater than output, shortness of breath, and +1 edema bilaterally in lower extremities.
  
  

i'm not sure if the second one sounds right because i tried describing what causes the pain, and in this case it's the gallstones (obstructing the common bile duct) and the pancreatitis. i also wasn't sure if i should include the diagnsostic studies (ultrasound:small stones and sludge within the gallbladder. gallbladder wall approx. 4mm, and ct scan: gallstones, dilated cbd and peri-pancreatic inflammation)

i was also thinking of using ineffective breathing pattern due to the pain and inflammation and maybe also due to the use of dilaudid which causes respiratory depression, and maybe the secretions could be a cause too???

and for the last one i was going to do imbalanced nutrition: less than body requirement related to reduced food intake (clear liquid diet), and increased metabolic needs...

i would really appreciate any feedback, it's really nice to bounce my ideas off other people.

:)

[leslie :-D]

your entire care plan sounds spot on, IF his breathing pattern IS ineffective.

what is his rr?

is he using accessory muscles to breathe?

shallow?

if ineffec breathing applies, then prioritize accordingly and i do believe you've done an excellent job.:)

leslie

[new_worker]

don't forget to use some p.c. as well:

potential complications

going down the list here:

activity intolerance, impaired comfort, impaired skin integrity

p.c: electrolyte imbalance, pc: dvt

interventions- cough deep breathing exercise, incentive spirometer, monitor lung sounds, t + r q 2 h, ongoing skin assessment, pain assessment, monitor i/o etc..etc..

and for you 2nd diagnoses :acute pain related to obstruction and inflammation of the common bile duct, inflammation, edema, distention of the pancreas, and peritoneal irritation as evidenced by patient reporting a pain of 8 on a 1 to 10 scale, the need for dilaudid

acute pain r/t gallstone pancreatitis s/t obstruction and inflammation of the common bile duct. aeb: pain of 8 on a 1 to 10 scale thats how i would write it, but good for you listing all those other ones so you understand why you are using that diagnoses

"i was also thinking of using ineffective breathing pattern due to the pain and inflammation and maybe also due to the use of dilaudid which causes respiratory depression, and maybe the secretions could be a cause too???"

monitor respiration rate, and lung sounds, loc a+o x3 some interventios to do

i like reading scenarios like this, keeps current on situations to deal with and using these scenarios to help me with others that i would deal with.

well this is getting to long ill let others follow up on this to

[schantzy143]

We are not aloud to use PC in our care plans, they tell us we need to use what is actually happening with the patient.

Any suggestions for short/long term goals for excess fluid volume? I don't lilke the ones my care plan book is giving me and I can't find ones that make sense.

I'm thinking something about monitoring the edema or reducing it?? I'm not sure how to word it so it makes sense with "Client will..." I'm also considering using, Client will remain free of jugular vein distention, positive hepatojugular reflex, and gallop heart rhythm throughout shift.

[netglow, ASN, RN]

Here is a handy little link I found on a search, and will give to you since you are such a good little student to post the work you've done first, instead of asking for the whole enchilada. It might help some time, when it's late and you get stumped on interventions, etc.

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm

And because you're such a good little student, take a break and here's some...

:cookies::hotchocolate:

[new_worker]

We are not aloud to use PC in our care plans, they tell us we need to use what is actually happening with the patient.

Any suggestions for short/long term goals for excess fluid volume? I don't lilke the ones my care plan book is giving me and I can't find ones that make sense.

I'm thinking something about monitoring the edema or reducing it?? I'm not sure how to word it so it makes sense with "Client will..." I'm also considering using, Client will remain free of jugular vein distention, positive hepatojugular reflex, and gallop heart rhythm throughout shift.

thinking of client will exhibit decreased edema [by enter time frame]

or client will have no crackles in lungs by end of shift

watch out for the oxygenation

Impaired gas exchange because of the SOB, and fluid building up

good site other person above me posted

[schantzy143]

thanks everyone for the help, very helpful :)

[WillowNMe]

Didn't read through the whole thing... but did you include knowledge based goals? Anything about TEDs or pneumo boots?

[schantzy143]

acute pain r/t gallstone pancreatitis s/t obstruction and inflammation of the common bile duct. aeb: pain of 8 on a 1 to 10 scale thats how i would write it, but good for you listing all those other ones so you understand why you are using that diagnoses

they always tell us not to use the medical diagnosis in here, even though it sounds better then the mess i have!

[new_worker]

acute pain r/t gallstone pancreatitis s/t obstruction and inflammation of the common bile duct. aeb: pain of 8 on a 1 to 10 scale thats how i would write it, but good for you listing all those other ones so you understand why you are using that diagnoses

they always tell us not to use the medical diagnosis in here, even though it sounds better then the mess i have!

i am not really diagnosing the person, i am just moving the words around that you already wrote in your post lol you have all the words their i just made it easier for you to read and understand :)

[schantzy143]

Maybe I am just confused, would you actually have the r/t gallstone pancreatitis part in there because that's what we can't have...they don't want any medical diagnosis in our care plan, even though it makes much more sense and it is easier to read.

"...related to obstruction and inflammation of the common bile duct, inflammation, edema, distention of the pancreas, and peritoneal irritation..."

I only wrote all of that because I was trying to explain that all of that caused the pain from the pancreatitis and gallstones

[Trilldayz,RN BSN]

Are you allowed to put any psychosocial diagnoses? Do they have family that come to visit? Is he total care? Here are some psychosocial dx ideas: loneliness, self care deficit, impaired health maintanance, possibly knowledge deficit (related to treatment). GOOD LUCK!