HELP: Nur Dx for Colovesical Fistula - Colostomy Pt

Published

Case:

-Med Dx- Colovesical fistula (post low anterior resection for rectal cancer)

-partial/end colostomy performed

-PICC; NPO, Feeding tube c enteral feeding cont 24h & free h20 q4h; 2L NC

-LESIONS: pressure ulcers (L heel, coccyx) & L/midline abdomen & L LE wounds (c wound vac)

-LABS:

  • INCREASED (na, chloride, glucose, BUN, creatinine, Alk ph, CK total/MB, total bili, PT, pH, WBC count, Neutrophils, urine (blood, protein, urobilinogen, nitrites, leukoctyes, bacteria)
  • DECREASED (O2 sat without NC, PCO2, Ca, total protein, albumin, prealbumin, INR, RBC, Hgb, Hct)

NEED:

TOP 4 nursing diagnoses; Possible options?:

  1. Risk for infection R/T recent invasive prodecure, multiple skin lesion, bacteria in urin, and increased WBC count.
  2. Risk for deficient fluid volume R/T deviations affecting fluid absorption, hypermetabolic state increasing fluid needs, and increased wound drainage
  3. Impaired skin integrity ....
  4. Risk for ineffective gastrointestinal tissue perfusion ..... ?
  5. Imbalanced nutrition: less than body requirements ... ??
  6. Ineffective breathing pattern ...?
  7. Risk for dysfunctional GI motility ...?

I don't feel very confident about these, and could use some advice/suggestions!

Thank you :-)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

There are many site on the internet to assist you. Always think in terms of urgency or life or limb. There is an excellent care plan nursing diagnosis area in the student section. Don't be so hard on yourself you are thinking along the right path. :)

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/.......an excellent care plan development site.

http://tinyurl.com/64m85du

There was a beloved mentor day to nite whp left us a legacy of love and learning.........

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

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For some reason it is hard for me to prioritize the diagnoses. i know it goes ABC's then Pain, but when your pt doesn't have problems with any of those things, then i get stuck. And now i'm wishing i would have gotten more information on my pt before i left the hospital i.e. on his breathing, etc. to see if i can even use "Ineffective breathing pattern", because all i know is that he is on 2L NC becuase his O2 sat was a little low. BLAH. Sometimes this is just frustrating.

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Specializes in Med Surge, Tele, Oncology, Wound Care.

I always did mine based on "what is going to kill them first." (morbid but the truth)

Risk for diagnoses were not diagnoses that my instructors liked because they are "risk for," and I am sure there are other things that put your patient in jeopardy that you can use.

Your "risk for infection," diagnosis is good, but if there is bacteria in the urine then they have an infection already so your diagnosis has occured.

So what is it that you are going to do with the patient?

I would go in the room and assess them.

What about pain? I am sure the patient would have some degree of pain related to the trauma of surgery. Pain scale teaching, medication administration teaching.

Patient is on oxygen...why? Are they on pain meds which can hinder respirations? They had a large abdominal surgery...so taking deep breaths is probably going to be difficult due to pain, swelling, gas...Data: RR rate, O2 saturations on and off oxygen, respiratory pattern (do they have shallow breathing- I would with a large abdominal wound). Breath sounds (any crackles?)

What can you do about it? Teach cough, deep breathing q every hour, teach incentive spirometry, teach patient pain assessment, teach splinting...

How are you going to evaluate your teaching? Did the patient demonstrate the use of the IS? Did the patient take the deep breaths you encouraged- did they verbally demonstrate the knowledge of the need for pulmonary toileting?

What about getting your patient to walk? Ambulation is very important post-op and part of pulmonary toileting. Impaired physical mobility (many iv lines, oxygen..AEB wounds...)

-If patient cant walk, what about use of interdisciplinary members (PT, OT). Can you do passive ROM every 2 hours? Can you get a softer air mattress? Floating heels?

Deficient fluid volume: what have the I's and O's been in the past 24 hours? Is there evidence of fluid imbalances like tenting? Dry mouth (you can provide oral care) any edema? Are the labs showing some evidence- like the increased labs you mentioned?

-I like what you had for this one!

Impaired skin integrity is another one you already listed AEB wounds, RT surgery, RT impaired mobility....

Imbalanced nutrition: AEB: decreased serum albumin, prealbumin, NPO status...ect.

Even though you only need 4 diagnoses, I would include a few more. I am sure that this patient has some emotional issues related to a colostomy, I know I would.

I was told once that a C nursing student would give the minimum required nursing diagnosis, but an A student would give more...

You are doing well! I dont know why you dont feel confident these are great! I didnt list the diagnosis in any order...

I know nurses dont actually do nursing diagnosis, but we do them in our heads all day long. Pt has o2 sats in the 70's well we then know what the cause could be (pneumonia) then we try to intervene...then we re-assess the outcome (did our intervention work?) So nursing diagnosis are very important!

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Thank you so much! I confirmed after reading your comment that i did not get enough information at the hospital when i went. i didn't look at I&O. i didn't record VS. The only thing i remember now, is that he had a pain of 0/10 for the past few days, so i knew pain wasn't a current factor. But you definitely helped fill in some blanks for me. We have a graphic analysis for our nursing diagnoses and it only has 4 spots, but your right, i could do more.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you so much! I confirmed after reading your comment that i did not get enough information at the hospital when i went. i didn't look at I&O. i didn't record VS. The only thing i remember now, is that he had a pain of 0/10 for the past few days, so i knew pain wasn't a current factor. But you definitely helped fill in some blanks for me. We have a graphic analysis for our nursing diagnoses and it only has 4 spots, but your right, i could do more.

Now you are learning what you need so that the next time you'll know!!!! you are on the right track!

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