Nursing Diagnosis for Post OP FESS Patient

  1. hi. i'm an incoming 2nd year nursing student, and i just finished my pre-clinical duty at the hospital. as a part of our requirement, we are asked to submit the nursing process, and two nursing care plans; actual and potential. i have already interviewed my patient and got some information. but, it does not seem enough. i need help in conducting this. i'm scared to make a mistake. :imbar

    here is the information:

    female patient, 22y/o,ht: 5feet and an inch, wt: 38kg. she was admitted to the hospital for operation,fess (
    functional endoscopic sinus surgery). she just got operated yesterday, may20,2009, at 1pm-8pm. when i interviewed her, she said that she had the sinusitis since elementary. it was only last 2007 that the child of her boss found some nasal polyps. he adviced the client to have a check up with the ent. it is this year that her boss told her to get her sinuses operated. as of now, she is currently a post operative patient. her record shows that she has allergic rhinitis, and that 2 years prior to admission, she has been having yellowish discharge with no foul smell. she sometimes complains about severe headaches, from the frontal sinus to the top of the head. the actual diagnosis that i can see now is allergic rhinitis (caused by pollution and some food). i was thinking of difficulty of breathing (her nose is covered and has wounds still from the operation) for her potential diagnosis.

    i really really really need help for this. i will be grateful if you give me some pointers for this one.

    if you want more information, please do not hesitate to pm me. thankyou.
    Last edit by nastassialeslie on May 21, '09 : Reason: forgot to indicate reason for DOB
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    About nastassialeslie

    Joined: May '09; Posts: 12; Likes: 8
    School Nurse; from PH
    Specialty: 1 year(s) of experience

    5 Comments

  3. by   nminodob
    Allergic rhinitis is not a nursing diagnosis - it's a medical diagnosis (and probably not the significant medical diagnosis in this case, since the patient had surgery for sinusitis, not allergies).
    A nursing diagnosis refers to something that we, as nurses, can do something about - we can't perform surgery, but we can make the patient more comfortable and assess for complications after the procedure. Because you seem unclear about what a nursing diagnosis is and how the nursing process is supposed to work, I suggest you look at your textbook for help, but some suggestions would be Alteration in Comfort, Pain, related to surgical procedure; Risk for aspiration; Impaired gas exchange; Risk for infection, Skin integrity impairment, and the list goes on...Good luck.
  4. by   Virgo_RN
    You might try posting your question in the Nursing Student Assistance forum (under the "Students" tab at the top of the page).
  5. by   Daytonite
    i post on the student forums all the time and specifically answer care plan and nursing diagnosis questions. it sounds like you are being asked to submit this as a case study. that would be done by organizing the paper by the steps of the nursing process and diagnosing the patient with 2 nursing problems (2 nursing diagnoses) which would constitute your 2 care plans (one actual and one would be a potential problem). on this thread in the student forums i go over how the nursing process is used in care planning: https://allnurses.com/general-nursin...ns-286986.html - help with care plans. this, however, is an analogy of how the nursing process works:
    you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).
    you will write up this clinical assignment focusing on this patient.



    step 1 assessment - assessment consists of
    • present a chronologic review of the pathophysiology, signs and symptoms and complications of the patient's medical conditions - the patient has these medical conditions which you need to discuss: sinusitis (which she has had since elementary school), allergic rhinitis, nasal polyps.
    • a health history (review of systems) - had yellowish discharge from nose with no foul smell and sometimes complained about severe headaches from the frontal sinus to the top of the head.
    • performing a physical exam - don't know that this was a requirement since you said that all you were required to do was an interview.
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - had fess (functional endoscopic sinus surgery) yesterday which is a medical treatment for the sinus problem.
    step #2 determination of the patient's problem(s) - understand that what the doctors did was medical treatment. we nurses do nursing treatment which is to help the patient learn how to respond to their medical condition and perform their activities of daily living. if you read the information about fess on the encyclopedia of surgery page then you will understand why i am targeting these two nursing problems:
    • actual: difficulty breathing (due to inflammation of tissues as a result of surgical trauma) [ineffective breathing pattern]
    • potential: changes in visual acuity (due to potential injury and/or inflammation pressing against the optic nerve) [risk for disturbed sensory perception, visual or risk for injury]
    step #3 planning (write measurable goals/outcomes and nursing interventions) - this is where i will leave you because most students can proceed from here.
    Last edit by Daytonite on May 21, '09
  6. by   cursedandblessed
    i enjoyed reading about this daytonite, when i had mine done in the dark ages endoscopy wasn't an option.
  7. by   Daytonite
    Quote from cursedandblessed
    i enjoyed reading about this daytonite, when i had mine done in the dark ages endoscopy wasn't an option.
    what was your post op experience like? any problems or concerns that you could share with the op?

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