you must follow the steps of the nursing process in the sequence that they occur in writing a care plan. you cannot determine any nursing diagnoses until you have a list of all your patient's symptoms. all nursing diagnoses are based upon the symptoms that your patient has
. every nursing diagnosis has a set of signs and symptoms and your patient must have at least one or more of them in order for you to apply that nursing diagnosis to the patient's situation.
so, having this list of your patient's symptoms is very, very important to the writing of your care plan.
the steps of the nursing process are:
- assessment (collect data from medical record, do a physical assessment of the patient, look up information about your patient's medical diseases/conditions)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
you can find explanations on how to write a care plan on these two threads:
n/g tubes tend to cause irritation of the mucus membranes of the nose and throat causing excess mucus production and sore throat. did your patient have any of that? the patient was npo. how are nutritional needs being (or not being) met. is d51/2ns with kcl in it providing enough nutrition for the patient? Attachment 5949
. how is the patient getting their adls (bathing, dressing, transferring from bed or chair, walking, eating, toileting and grooming) accomplished? do they need any assistance with them? if so, then there are self-care deficits to be addressed. these are all things that need to be assessed in step #1 of the nursing process before moving on to picking nursing diagnoses.
the only symptoms you have listed are abdominal distension and diarrhea. however, with a small bowel obstruction i am sure there are more that you either haven't posted or have overlooked. did the doctor's notes indicate why the bowel obstruction was occurring? does this patient have abdominal pain? were there bowel sounds? did you look up information about small bowel obstructions? quite often these patients tend to lose fluid because it becomes trapped in the bowel and since peristalsis is either slowed or shut down, the fluid just sits in the bowel or is lost through diarrhea. it would be interesting to see what a set of this patient's electrolytes looks like. so, knowing that pathophysiology, you have a potential nursing diagnosis of:
- (risk for) deficient fluid volume secondary to small bowel obstruction r/t fluid loss through bowel aeb distended abdomen and diarrhea