Nursing diagnosis

  1. I am working on a care plan for a patient with small bowel obstruction. This patient has an ostomy. The care plan is to be only a nursing diagnoses and I have no idea where to start. Any help would be greatly appreciated. I am totally new to this and do not know where to begin.
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  2. 5 Comments

  3. by   beth66335
    First do you have data? You need an assessment of the patient or info from the chart. Now take that data and cluster it by similarities like cardiac, or respiratory, etc you are looking for problems or potential problems but don't use the medical diagnoses the doctor has assigned. Nurses do not treat the medical Dx we treat problems associated with it, the signs and symptoms. Now get your nursing diagnoses book or look at the NANDA list in your textbook. Assign a NANDA Dx based on your clustered data and state r/t (related to) a piece of info from your clustered data. Ex. Nutrition: less than body requirements r/t interrupted elimination. Or pain is a good one, risk of infection can work too. Just look at your data clusters and a Nursing Dx should jump out at you. Hope this helps!
  4. by   RN BSN 2009
    hm. do i see a risk for disturbed body image
  5. by   Daytonite
    well, i'm not totally understanding what it is that you are supposed to be doing. are you supposed to do a care plan up to the point of developing nursing diagnoses? no goals or interventions?

    a care plan is nothing more than the nursing process written down. the steps of the nursing process are:
    1. assessment (collect data)
    2. nursing diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    so, the first thing you need to do is look at the data you collected. this data will come from your physical assessment of the patient and from the data you collected from the patient's medical record. you are looking for abnormal data--anything that isn't part of a normal examination. for a patient who has had surgery and now has an ostomy there are some things that you might have noticed:
    • breathing problems (an indication of atelectasis, hypoxia, pneumonia, pulmonary embolism)
    • hypotension (an indication of shock, hemorrhage)
    • thrombophlebitis in the lower extremity
    • elevated or depressed temperature
    • any number of problems with the incision/wound (dehiscence, evisceration, infection)
    • fluid and electrolyte imbalances
    • urinary retention
    • constipation
    • surgical pain
    • nausea/vomiting (an indication of a paralytic ileus)
    • skin excoriation around the stoma
    • bleeding or leakage from the stoma
    • patient having difficult accepting/dealing with the presence of the stoma
    • the patient needs teaching on how to care for the stoma
    if the patient has any of the above, these would be abnormal assessment items that would need to be addressed in your care plan. this abnormal data is actually signs and symptoms. each sign and symptom can be matched to signs and symptoms (nanda actually calls them defining characteristics) listed under specific nursing diagnoses. each nursing diagnosis has specific defining characteristics (signs and symptoms) that must be present in order for you to assign it to a patient. just like a doctor cannot randomly say a patient has a disease without certain specific symptoms being present, the same applies to nursing diagnoses. and, that is how to get to the second step of the writing the care plan which is determining what your nursing diagnoses are. you need a nursing diagnosis reference book or a care plan book to help you pick a diagnosis correctly.

    so, my next question for you is if this is a real patient that you had, what were the abnormal assessment items that you found? if you post them i will help show you how to choose nursing diagnoses that match with them.

    goals and nursing interventions which are done in step #3 of this process are actually based upon all the patient's signs and symptoms that you found during your assessment, but it doesn't sound that that is a part of your assignment.

    you can find more information on choosing nursing diagnoses on these two threads:
    these posts have information on care planning for a postoperative patient:
  6. by   mickeyfan
    yes, it is only nursing Dx. Nothing else. So, what would be a good place to start. I really do not have a lot of info on patient, just the medical diagnoses from the chart and vitals. That is why I am having trouble. Where can I find more info on this medical Dx to make my care plan for a nursing Dx?
  7. by   Daytonite
    i see. your nursing diagnoses have to be based on signs and symptoms that the patient has. were the vital signs within normal limits? if so, then they cannot be used as a sign or symptoms. you'll have to back door into this using the medical diagnoses. they are. . .the small bowel obstruction and surgery to have the ostomy, correct? anything else?

    i posted the common signs and symptoms of the side effects experienced by patients who undergo general anesthesia as well as 4 items that specifically pertain to having a stoma (colostomy). did the patient have any of those symptoms? does this surgical patient have any incisional pain? at the very least the patient will need teaching regarding the care of the colostomy. these two things lead to two nursing diagnoses:
    • acute pain
    • deficient knowledge about care of colostomy
    are there any other medical problems that this patient has? in it's most simplest definition, a nursing diagnosis is nothing more than a nursing problem that the patient has that we nurses need to deal with. so, with a postoperative patient with a colostomy the kinds of things you are generally dealing with are things like the patient's pain, attention to the incision and dressing, sometimes issues involving their diet and what they can and can't eat, iv fluids and teaching them about how to take care of the colostomy by the time they are discharged home. there are nursing diagnoses that cover all of these items.

    here is information on colostomies:
    in the future, when you are assigned to a patient in the clinical area that you are going to have to do a care plan on, it is extremely important that you take the time to go through the patient's chart to copy down important information. this may take as much as an hour to do, but that information is crucial to constructing the care plan. the entire care plan is based upon the assessment information that you obtain. this post will tell you what information in the chart is important to copy down: http://allnurses.com/forums/2228927-post5.html. you should also be doing some sort of physical assessment of your patient. you can get a basic guideline of a systems assessment if you open up and print out a copy of the clinical report sheet for one patient attached to the bottom of each of my posts. there is also information on doing physical assessments of patients on this sticky thread in the nursing student assistance forum: http://allnurses.com/forums/f205/hea...ms-145091.html - health assessment resources, techniques, and forms

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