Nursing diagnosis HELP please!

[wackyj2000]

Hello everyoneeee.. so my head is not with it tonight i think im over thinking the whole nursing diagnosis thing.. ive done so many care plans now im not sure why im stuck in a rut. My patient came in for umbilical hernia repair and now has a binder on post op. but he also has a pmh of acites, alcohol cirrhosis, smoking 2 packs a day. drinking 3-4 drinks e/o day. He suffered from some post op complications and had to go back to the OR, they had take out 2ml of ascitis from his stomach. He was on a liquid diet yesturday and is now onto food. He also has colace orders, so was thinking increased risk for constipation? I havent met this patient yet ,and my instructor wants me to come up with 3 diagnosis and try to make a care plan... any good nursing diagnosis for me besides increased risk for infection?????? I was trying to figure out if i could do PC: deficient fluid volume or would it be excess fluid volume? hm confused.. Hope someone can help! Thanks guys. :redbeathe

[Annisme]

Hmmm....

Risk for ineffective breathing pattern r/t compromised cardiac/pulmonary function (smoking)

Risk for ineffective tissue perfusion: peripheral r/t circulatory stasis (bedrest after surgery)

Risk for pneumonia (post op)

Risk for activity intolerance r/t pain, surgical procedure

Hope this helps!

Annisme

[Daytonite, BSN, RN]

diagnoses are decisions or opinions made after a process of examination or investigation of the facts. medical diagnoses are always based upon the symptoms the doctor observes in the patient as well as the medical data he/she collects. nursing diagnoses are no different except that we do an assessment of the patient that involves talking to the patient and going through a similar review of symptoms as well as assessing adls. we also read the patient's medical record, as well as look up information about the patient's medical condition (it's signs and symptoms) and perform our own physical assessment. we compile the abnormal data (symptoms) and make a nursing decision (nursing diagnosis). the criteria (rules, standards) for the formation of nursing diagnoses is different from the criteria for the formation of medical diagnoses. using a nanda publication like nanda-i nursing diagnoses: definitions & classification 2007-2008 or a care plan/nursing diagnosis reference that contains that information will spell out the specific criteria required for each nursing diagnosis. [the definition of criteria: standards, rules or tests by which a judgment of something is made.]

by extracting information from this patient's medical record, using the symptoms the doctor found during his examination until you can perform your own assessment, looking up information about the signs, symptoms and potential complications of umbilical hernia repairs (http://www.surgeryencyclopedia.com/st-wr/umbilical-hernia-repair.html), ascites, and alcoholic cirrhosis, and adding what you know about the post op effects of anesthesia (https://allnurses.com/forums/f205/appy-195227.html#post1969425) on the patient undergoing major surgery, you should be able to compile a list of abnormal data (symptoms) with the patient site unseen that should net you more than 3 nursing diagnoses of actual nursing problems. you can incorporate the treatments already ordered for the patient into the care plan as nursing interventions (the abdominal binder is to provide abdominal support, hold dressings in place, and reduce tension on wounds and suture lines and this patient does have ascites and has had to have a paracentesis since surgery; he was on clear liquids because peristalsis in the gi track shuts down when the gut is opened up and touched during surgery and needs time to restart or the patient will be puking up the food he eats; the colace may be for constipation but did you check the admission assessment to see if this is a problem that he has regularly). i'm curious as to why only 2 ml of peritoneal fluid was removed from this man's ascites. that sounds more like a specimen for culture to me. do they think he has some malignancy or infection going on? i would read the doctor's progress notes.