I'm writing a concept map for bowel elimination for simulation lab. I need just one nursing diagnosis, and my teacher told me to use "alteration in elimination", but my diagnosis book doesn't have that...and I can't really find it online.
Here's the scenario:
My "patient" has an ileostomy due to fecal drainage into an abdominal wound. They diverted the stool to allow the abd wound to heal better.
I essentially was thinking: Alteration in elimination R/T ileostomy bowel diversion AEB...and that's where I struggle. I want to say AEB a pouch attached to her abdomen and stool in it! But I'm sure that wont be acceptable.
Ileostomy is secondary to the hemicolectomy & wound dehiscence otherwise sounds good
Sorry...is that not the way I have it? My brain is mushy. I have first the hemi and dehiscence, and an ileostomy secondary to that...yes?
Delayed surgical recovery R/T extensive or prolonged surgical procedure AEB dehiscence hemicolectomy wound site secondary to ileostomy to divert stool away from wound bed.
Specializes in Complex pedi to LTC/SA & now a manager.
Sorry...is that not the way I have it? My brain is mushy. I have first the hemi and dehiscence, and an ileostomy secondary to that...yes?
Delayed surgical recovery R/T extensive or prolonged surgical procedure AEB dehiscence hemicolectomy wound site secondary to ileostomy to divert stool away from wound bed.
You have it backwards in my experience. The way you have it written the wound opened d/t the ileostomy.
Try this: ( read both aloud if you need to)
Delayed surgical recovery R/T extensive surgical procedure AEB ileostomy to divert stool away from wound bed secondary to dehiscence hemicolectomy wound site and stool present in wound bed.
You have it backwards in my experience. The way you have it written the wound opened d/t the ileostomy.
Try this: ( read both aloud if you need to)
Delayed surgical recovery R/T extensive surgical procedure AEB ileostomy to divert stool away from wound bed secondary to dehiscence hemicolectomy wound site and stool present in wound bed.
Okay okay, I see (hear) it. ha, thank you. I have been doing this all day, plus helping classmates with theirs and editing my group's presentation...blablabla, excuses, whatever, but dang, my brain is fried! I just posted this to FB:
Ineffective self-health management R/T excessive demands made AEB ineffective choices in daily living for meeting health goals, secondary to NURSING SCHOOL.
Which, I realize is not an exactly accurate dx, but I think its falsities speak for itself. :)
While we're at it....these are the interventions I intend to use...if no one cares to comment, I understand, but if there's something seriously wrong with them, I'd love to know. I'd also love to sleep. But nursing school comes first! :)
Assess nutritional status and current intake with MNA every 2 days-increase kcal intake daily as tolerated until goal of 1700kcal/day; Record I&O daily
Inspect incision and stoma q8h and describe any changes
Include stoma therapist to provide self-care teaching and aid in altered body image risks
Educate pt on ileostomy and stoma self-care. Pt will verbalize understanding and exhibit correct self-care techniques within 2 days
Specializes in Complex pedi to LTC/SA & now a manager.
You can also consult with dietician and educate current dietary recommendations for ileostomy patients such as recommendations to reduce excessive gas, malodorous stool (I know at one point buttermilk was a recommendation, reduce consumption of nuts & seeds but that likely changed. These are not issues I usually encounter in my medically complex/fragile pedi patient population. Heck if one of my kiddos managed to ask for nuts or seeds I would run out & buy it for them!)
Good start though! You can try googling nursing care plan for patient with ileostomy for some more ideas to implement.
In nursing school I had a new stoma patient (emergency bowel diversion) who wouldn't even look at her site...until I got there. The fact that I didn't react to the (honestly not that bad) odor when emptying & changing her pouch have her the confidence to look. She was willing to try the change herself if I helped. I grabbed the WOCN who was in the hallway with my instructor and voilà my first patient teaching experience. I had my initially sullen patient & her roommate roaring with laughter when I told her she had a new trick literally under her belt. Bad company? Accidentally vent the pouch...they will leave you alone ASAP. Works for grand kids & in-laws too.
And now off to bed as I have a new infant patient in the morning.
Thank you immensely!! My "patient" isn't taking any food at all right now...well she wasn't when I was there, a week ago...lol. Sim lab, what can I say? So I feel like right now, the best plan is to get her to be eating anything. But the ideas of making stool less noxious is something I never would have thought of, and now wont forget! I will probably try to throw it into a convo with my profs, see if I can get a raised eyebrow or two :)
Thank you so much for helping, some days nursing school just fries us, I'm sure you know!!!
Have a good night, and a great day with the wee ones tomorrow!
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thanks Beachy! Great stuff..busy day yesterday I am bushed.
I have to admit...without a good "story" for your manikin it is REALLY difficult. Care plans are all about patient assessment and what they say without that it's tough to "make up". Maybe I need to write a book for instructors of simlab about coherent case studies.
The surgical wound dehisced? THAT IS HUGE! Stool in anything but the rectum spells TROUBLE!
Risk for infection (is she doesn't already have one)
Delayed healing
Pain
Impaired tissue
nutrition less than (NPO)
Deficient knowledge
When your instructor asks about altered nutrition tell her you looked for it....according to NANDA I 2012-2014 it is no longer listed as a current diagnosis.
Right. yes, I do have a book. That's why I know there isn't one that fits...I just worry that my teacher will have something to say about it.
Ok, so then how about this.
Delayed surgical recovery R/T extensive or prolonged surgical procedure AEB dehiscence hemicolectomy wound site secondary to ileostomy to divert stool away from wound bed.
There is no such defining characteristic for this diagnosis as "dehiscence due to ileostomy." The ileostomy didn't cause her wound to rupture open. That doesn't really make sense, anyway, does it? "Secondary to" means "caused by," not, "I thought it had something to do with it because it's there, right?" :)
I also think you need to look a little further down the list of related factors on p. 440-- "...related to postoperative surgical site infection, extensive surgical procedure, and (?)obesity" come to mind, and yes, it is perfectly acceptable to let the instructor know that you recognized more than one cause for the hot mess in this unfortunate (even if hypothetical) woman.
Then your defining characteristics: Dehiscence isn't on the list, is it? But it is obviously there in front of you. The way you document that with something that is an approved defining characteristic is, "... as evidenced by evidence of interrupted healing in the surgical area (dehiscence on DATE, fecal drainage)."
This is what I went with. Turned it in yesterday, I'll let you know how ravaged it is when I get it back
Delayed surgical recovery R/T extensive or prolonged surgical procedure AEB ileostomy to divert stool away from wound bed secondary to dehiscence hemicolectomy wound site and stool present in wound bed.
And thank you all immensely for taking time to help! The story part is indeed hard, the mannequins script thru a teacher who is also aiding another few groups of students makes it hard to get a full anything.
I'm not sure if she actually has ileus. Did she have an abdominal xray to evaluate gas pattern? Not moving bowels 24 hours after surgery is not uncommon. Plus she may not have anything in the bowel to come out. The bowels take time to wake up, so you may not hear good bowels sounds.
JustBeachyNurse, LPN
13,957 Posts
Ileostomy is secondary to the hemicolectomy & wound dehiscence otherwise sounds good