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