Help with Nursing Diagnosis

  1. I am a first year RN nursing student. I am in my first week of clinicals, and I need some extra help.
    I have a 65 year old patient who was admitted to the hospital with Abdominal pain, and vomiting. She had a colonoscopy which showed an ileus. She has COPD, Diabetes and peptic ulcer disease. My question is, I have to come up with 3 Nursing Diagnoses for her. Does anyone have any suggestions? Thank you so much for your help.
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  2. 10 Comments

  3. by   fitzarelly
    well i have no help but maybe u can help i am a nursing student as well cant figure out how to post on this site need help with a care plan, what .....risk for deficient fluid volume R/t vomiting thats about as far as my expertise goes
  4. by   fitzarelly
    any suggestions i allready have 1 dependent action i was planning on using contacting physician to hold off on lasix until pt is no longer vomiting and can hold down fluids and solids any suggestions is this an appropriate dependent nursing action
  5. by   Hellllllo Nurse
    These are med dx which have a lot of NDX possibilities. Your careplan book will have tons.
  6. by   Daytonite
    i can tell you are new at this! the process of writing a care plan involves 5 steps. they are (1) the collection of data or information about the patient, (2) grouping the abnormal assessment data items into nursing diagnoses, (3) planning the care which involves determining outcomes and nursing interventions, (4) putting the plan into action, and (5) evaluating the effectiveness of the plan. this is a cycle that repeats itself continually until a nursing diagnosis is resolved or abandoned and replaced with a new one.

    the only abnormal assessment items you have given are abdominal pain and vomiting. however, from the four medical diagnoses you've listed i'm suspecting there is a lot more potentially going on with this patient. i would suggest that you review the signs and symptoms of an ileus, copd, diabetes and peptic ulcer disease. if your patient also has some of those same symptoms, you need to use them in supporting nursing diagnoses. doctors aren't the only ones who have exclusive use of symptoms in formulating their medical diagnoses. we can use them to formulate nursing diagnoses as well. i am, in particular, thinking about a possible connection between the diabetes and the ileus. diabetic patients sometimes have a complication called gastroparesis and i'm wondering if this patient might have had problems with that in the past, or currently, and if it might be contributing to the development of the ileus. you also need to look at the nursing implications and follow-up care for a colonoscopy. the bowel is often inflated with air during the procedure that contributes to abdominal cramping and pain. if biopsies were obtained, the patient might have some bloody rectal discharge. this carries a risk of developing an infection. all potential things that could contribute to nursing diagnoses. all of these factors carry potential symptoms that you may have missed picking up in the patient's chart or even noticing yourself. also, what kind of copd does the patient have: chronic bronchitis or emphysema? with one there will be more sputum production as opposed to the other. people with emphysema are more prone to be "pink puffers" where as those with chronic bronchitis are the "blue bloaters" and tend to get cyanotic. either way they may have problems with gas exchange in their lungs.

    here are three possible nursing diagnoses. i would caution you to make sure you have patient assessment data to back them up if you use them. anything between brackets is just information i'm guessing at. i've also linked you into online information about each of these nursing diagnoses at two different websites.

    deficient fluid volume r/t loss of fluids from vomiting and fluids segregated in the bowel aeb [abdominal distension]
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=21
    http://www1.us.elsevierhealth.com/ev...replan_030.php

    acute pain r/t [abdominal distension] aeb abdominal pain
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=40
    http://www1.us.elsevierhealth.com/ev...replan_052.php

    risk for ineffective airway clearance r/t chronic obstructive pulmonary disease [increased production of secretions, retained secretions, bronchospasm] aeb ????
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=02
    http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_002.php
  7. by   smk1
    Right away I would think about her pain so maybe "Acute pain related to Ileus", something like "fluid volume deficit related to emesis and diarrhea", look in your nursing diagnosis reference and you will find a lot to work with for this patient.
  8. by   angelcharm
    your patient has a serious problem and many diagnosis can be generated from her condition. what you need is a good assessment to come up with a diagnosis.

    u can start with these.. but remember it has to match with your assessment
    pain, fluid electrolyte imbalance, fluid volume deficiency, fatigue, nutrition altered less than body requirement, ineffective airway clearance, impaired gas exchange, risk for infection...
  9. by   Daytonite
    Under NANDA guidelines you cannot write a nursing diagnosis as Acute Pain related to ileus because "ileus" is a medical diagnosis. Ileus is an acute intestinal obstruction. The pain that is produced is not from the obstruction itself, but from the spasm of the muscles of the intestine and as a result of swelling due to engorgement of the intestine with fluid. As the intestine and bowel distends with this fluid, it presses on the other internal organs and nerves which is what ultimately produces the pain. This fluid that is trapped in the intestines and bowel in an ileus is also a source of great fluid and electrolyte loss. When you are determining causes of nursing diagnoses and know them to be due to a medical condition, you need to know and understand its pathophysiology.
  10. by   smk1
    Quote from Daytonite
    Under NANDA guidelines you cannot write a nursing diagnosis as Acute Pain related to ileus because "ileus" is a medical diagnosis. Ileus is an acute intestinal obstruction. The pain that is produced is not from the obstruction itself, but from the spasm of the muscles of the intestine and as a result of swelling due to engorgement of the intestine with fluid. As the intestine and bowel distends with this fluid, it presses on the other internal organs and nerves which is what ultimately produces the pain. This fluid that is trapped in the intestines and bowel in an ileus is also a source of great fluid and electrolyte loss. When you are determining causes of nursing diagnoses and know them to be due to a medical condition, you need to know and understand its pathophysiology.
    This is true! sorry, (looked funny when I wrote it too! lol) but the acute pain should at least lead you to the page where you can see the major defining characteristics and what you can use for the "related to" and "secondary to" if need be.
  11. by   Alexsys
    Quote from daytonite
    here are three possible nursing diagnoses. i would caution you to make sure you have patient assessment data to back them up if you use them. anything between brackets is just information i'm guessing at. i've also linked you into online information about each of these nursing diagnoses at two different websites.

    deficient fluid volume r/t loss of fluids from vomiting and fluids segregated in the bowel aeb [abdominal distension]
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=21
    http://www1.us.elsevierhealth.com/ev...replan_030.php

    acute pain r/t [abdominal distension] aeb abdominal pain
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=40
    http://www1.us.elsevierhealth.com/ev...replan_052.php

    risk for ineffective airway clearance r/t chronic obstructive pulmonary disease [increased production of secretions, retained secretions, bronchospasm] aeb ????
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=02
    http://www1.us.elsevierhealth.com/ev...replan_002.php
    these are the ones i would have went with
  12. by   lasie2005
    Daytonite i got a 64 yo widow was diagnosed w/an inoperable lung cancer, apart from pain fatigue breathlessness constipation and limited mobility. She express a life of emptiness and despair following the death of her husband and her son who committed suicide since her arrival at the hospital she has been angry and not cooperating w/nurses.
    Can you pls help me, i need a nursing diagnosis and i dont know where to start

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