CNA253 - Patient Scenario, Nursing Diagnosis, and Care Plan Assignment

This CNA253 assignment focuses on a patient case study, Ms. L, a 39-year-old woman presenting with nausea, vomiting, and abdominal pain. The student identifies and prioritizes two nursing diagnoses: deficient fluid volume and acute pain, providing rationale based on patient assessment findings such as weak pulses, reduced skin turgor, and elevated hematocrit and lipase levels. The assignment includes goals, related nursing actions with rationales, and expected outcomes for each diagnosis. The student also reflects on the case, suggesting a possible diagnosis of intestinal obstruction and the need for further investigation with CT scans, emphasizing the importance of fluid balance, pain management, and patient comfort. References are also provided. The assignment demonstrates understanding of patient assessment, nursing diagnosis, care planning, and evaluation of outcomes.

CNA253 AT3 1
CNA253 AT3
By Student’s Name
Course + Code
Class
Institution
Date

CNA253 AT3 2
CNA253 AT3
Scenario
Ms. L, a 39 years old lady.
Two Priority Nursing Diagnosis
1. Deficient fluid volume related to vomiting and increase in hematocrit as evidenced by
patient passing regular small bouts of vomiting and feeling nausea with a hematocrit
of 50%
2. Acute pain related to vomiting and bowel distention as evidenced by patient waving
on the upper abdomen when asked about pain and failing to void.
Reason for the prioritization
1. Deficient fluid volume is a priority diagnosis due to the fact that the patient exhibited
hydration characteristics such as weak pulse, reduced skin turgor, capillary refill
greater than three seconds, dry mucous membrane, pale and cool to touch and
increase in urine concertation. Other than that, the patient has been having small bouts
of vomiting with little oral intake
2. Acute pain is a priority as it put the patient in distress. Ms. L when asked about, she
just pointed at her upper abdomen without speaking meaning she is in deep pain. S
Goals, Actions, and Evaluation
Diagnosi
s 1
Goal Related Actions Rationale Evaluate
outcomes
Deficient
fluid
volume
To maintain Ms.
L with adequate
body fluid
volumes by
maintaining the
1. Monitor Ms. L
vital signs and
record as
required
(Gulanick, and
1. Ms. L is in
distressed and has
difficulty in
breathing with a
capillary refill greater
1. The pulse rate
should increase
and become
stronger with a
capillary refill

CNA253 AT3 3
blood pressure,
decrease
hematocrit levels
from 50% to
normal ranges,
increase venous
filling, urine
output, maintain
patient mucus
membranes and
acid, base, and
other body
electrolytes
balance within 48
hours following
admission.
Myers, 2013).
2.Monitor input
and output for
Ms. L by
encouraging
small sips oral
intake or through
an intravenous
infusion(Freema
n, 2013)
than 3 sec, weak
pulse and in pain.
Vital signs act as
basic parameters that
will be used to
indicate any
deterioration or
improvements for
Ms. L (Gordon,
2014).
2. Input and output
help to monitor body
fluid balance and
elimination. Ms. L
has stayed for
sometimes before
voiding. Infusing
with intravenous
fluids like Normal
Saline will balance
body electrolytes,
reduce high levels of
lipase and amylase,
hydrate body mucus
membranes, and
less than 3
seconds in less
than an hour.
2. Body lipase
and amylase
lipase should be
between 10-
60U/L, amylase
70-400U/L,
haematocrit of
37-47%, PCO2
to be 35-
45mmHg and
HCO3 to range
between 22 to
28mmol/L per
litre in the first
48 hours after
several repeated
blood tests.
3. Ms. L mucus
membrane will
have come to
normal, with
urine output of

CNA253 AT3 4
finally cater for loss
fluid through
vomiting (Gulanick,
and Myers, 2013).
30cc/hour and be
able to void.
Diagnosi
s 2
Goal/s Related actions Rationale Evaluate
outcomes
Acute
Pain
Ms. L should be
able to verbalize
that she no longer
feel upper
abdominal pain in
the first 12 hours
after admission.
1. Assesses Ms.
L pain in 4 hours
interval (Srinath
et al, 2014).
2. Insert a
nasogastric tube
for drainage and
decompression
(Gordon, 2014).
Pain assessment and
monitoring will
indicate
improvements of the
patient and if
interventions are
working or not
(Freeman, 2013).
2. Drainage and
decompression will
help to remove
gastric content thus
creating a pathway.
This, in turn, will
reduce pressure thus
reducing pain,
distress and
enhancing fluid
intake (Gordon,
By 12 hours Ms.
L should
verbalize
decrease pain. A
pain scale of 1-
10 should be
ranging between
1-3 by the above
time.

CNA253 AT3 5
2014)
Reflection
Following the symptoms presentations, CT scans Blood results and Hydration assessment of
Ms. L and she could be having intestinal obstruction disease. She has not voided for some
times with small bouts of vomiting and has upper abdominal pain indicating it could be small
bowel obstruction (Freeman, 2013). A CT scan is usually indicated to determine the best
option for treatment. Such patients unusually have distorted body fluids and electrolytes thus
affecting input and output plus heart rate and body pressures (Freeman, 2013). Best nursing
interventions should focus on fluid balance; relieve pain, and patient comfort.
Reference list
Freeman, L. (2013). Responding to small-bowel obstruction. Nursing, 37(5),
pp. 56hn1-56hn4.
Gordon, M. (2014). Manual of nursing diagnosis. Sudbury, Mass.: Jones and
Bartlett.
Gulanick, M. and Myers, J. (2013). Nursing care plans. St. Louis, MO: Mosby.
Srinath, A., Young, E. and Szigethy, E. (2014). Pain Management in Patients with
Inflammatory Bowel Disease. Inflammatory Bowel Diseases, 20(12), pp.2433
2449.