First Care Plan CONFUSED

[DeLovely]

Okay well this is my first few weeks of my nursing program. I was given a short description of a client. I am supposed to come up with all possible diagnosis and then do a care plan on the most important one. My client is 44 years old and 2 days post op. from a abdominal hysterectomy. Incision is clean and and dry and well approximated. Patient has a indwelling catheter that is due to come out this am. Urine is clear. Patient states she does not like carrying Cath bag with her down the hallway. She is sleeping and eating well. She just came off of a 24 hour liquid diet. Has gas pains and bowel sounds in all four quadrants. Client states she has not had a bowel movement since the enema before surgery. Post op orders include - ambulation QID, a stool softener BID,Fleet enema prn 3rd day post op, morphine IM for pain.

So far possible nursing diagnosis I have are,

Acute Pain

Constipation

Risk for infection

Disturbed body image

My problem is how many characteristics does the client have to present for the diagnosis to be accurate? For acute pain the client presents at least two characteristics but I am not sure if I can use them since it is subjective.

Please help all responses welcome

thanks!

[Daytonite, BSN, RN]

in https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans i post about the construction of care plans all the time including the prioritization of the nursing problems. use the nursing process to help you organize. since you have been given all the assessment data that the instructors want you to know and work with it is a matter of pulling it out of the scenario and organizing it. nursing problems (nursing diagnoses) are always based upon abnormal data. this is the abnormal data from the scenario:

• has gas pains
  
• no bowel movement since the enema before surgery
  

the nursing diagnosis is acute pain r/t surgical intervention aeb gas pains. is it possible for her to be constipated if she had an enema before surgery?

you should also look up what an abdominal (open) hysterectomy is. see http://www.surgeryencyclopedia.com/fi-la/hysterectomy.html. with any open procedures of the abdomen, surgical ileus is always an expected complication which is why the patient is kept npo and assessed for the return of bowel sounds. why? peristalsis shuts down the moment the intestines are handled by the surgeon and air begins to collect in the bowel. the gas pains the patient is now having is that built up gas beginning to make its way through the gi tract as peristalsis is restarting. it hurts and thus the gas pains. see http://www.merck.com/mmpe/sec02/ch011/ch011g.html. post op complications that we routinely monitor for are as a result of having anesthesia are:

• breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  
• hypotension (shock, hemorrhage)
  
• thrombophlebitis in the lower extremity
  
• elevated or depressed temperature
  
• any number of problems with the incision/wound (dehiscence, evisceration, infection)
  
• fluid and electrolyte imbalances
  
• urinary retention
  
• constipation
  
• surgical pain
  
• nausea/vomiting (paralytic ileus)
  

the nursing interventions would be to medicate this patient for pain and encourage her to ambulate to help get things moving. by the doctor's orders, however, you cannot give a fleets enema because it is not yet the 3rd post op day.

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so far possible nursing diagnosis i have are,

acute pain - ok

constipation - ok

risk for infection - ok

disturbed body image - there is no evidence of this

i'd include

impaired skin integrity

and

risk for urinary retention

(when the foley is removed later this morning due to edema in the area and receiving opioids)

how many characteristics does the client have to present for the diagnosis to be accurate?

all you need is one as long as it fits with the definition of the nursing diagnosis and there is an etiology (cause) for it that makes sense. whether the evidence is subjective or objective doesn't matter. it's evidence. it's contributing to a problem that is present and our job is to address the problem and not ignore it. that is scientific (rational, critical) thinking.

[DeLovely]

Bless you daytonite! You really helped me put it all together. I am only about 3 weeks into class and became a little confused!

Thanks thanks thanks thanks!