Help with Nursing Diagnosis

a care plan is a determination of the patient's nursing problems and strategies to do something about them. this patient wouldn't be hospitalized if nursing assistance weren't needed to help him. otherwise, the doctor would have been able to do what had to be done for the patient as outpatient procedures. so, think about what was being done by the nursing staff and how those fit into actual nursing problems (nursing diagnoses). look at the diagnostic procedures being ordered and the medications being given and their side effects.

problems are based upon the evidence you see. every crime has evidence; every nursing problem (nursing diagnosis) has defining characteristics (the nanda term for symptoms). since you are thinking about using acute pain, what led you to this conclusion? you didn't just pick this out of the thin air. there was evidence that this patient had discomfort.

diagnosing is the result of logical problem determination. you must systematically break down information you obtain from the patient's medical history, physical examination, and laboratory tests and reassemble it into patterns that fit well-defined groupings of symptoms that describe nursing diagnoses. you use your knowledge of the person's diseases and their treatment, the nursing process and a nursing diagnosis reference to help you.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - double check the symptoms of the sbo and scleroderma against what you observed and assessed in the patient. did you overlook anything? why was this patient placed on tpn? what would be the nursing problem for that? why do you think the patient also is receiving iv fluids along with the tpn? (http://www.merck.com/mmpe/sec02/ch011/ch011g.html) what goes on with a patient's fluid status when they have a bowel obstruction? how can fluids be lost with a bowel obstruction? (http://www.merck.com/mmpe/sec02/ch011/ch011h.html) what might be the reason for a bowel obstruction? what happens to stools and stool elimination when there is a bowel obstruction? was there a previous surgery that might have resulted in adhesions and scar tissue? after reading about scleroderma can you make a case for the patient's cardiac and gi history to be related to the scleroderma? what fear/anxiety might the patient be facing? what teaching and preparation does the patient need for the upcoming surgery? what are the complications of bed rest and immobility? there was a thread about this yesterday that i replied to on the general nursing student discussion forum: https://allnurses.com/forums/f50/discussion-question-immobility-342206.html. many of these are actual nursing problems that need to be addressed.

• sbo - scheduled for surgery to relieve sbo
  
• 40-60lb weight loss within past 6 months of unknown cause
  
• previous hospitalization in july for n/v and abd pain
  
• scleroderma
  • http://www.merck.com/mmpe/sec04/ch032/ch032h.html

  [*]history of pericardial effusion

  [*]dilated cardiomyopathy

  • medical treatments:
    • right picc
      
    • tpn
      
    • d51/2ns 50ml/hr
      
    • has an ng tube to suction
      
    • hiv testing pending
      
    • bed rest

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• complains of weakness
  
• back pain due to bed rest and positioning
  
• add
  • assessment of abdomen
    
  • fluid and electrolyte abnormalities
    
  • knowledge needs regarding surgery and post op care

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• deficient fluid volume r/t fluids trapped in small bowel aeb [symptoms of the bowel obstruction]
  
• imbalanced nutrition: less than body requirements r/t inability to digest food secondary to esophageal and intestinal dysfunction due to scleroderma aeb 40-60 lb weight loss within past 6 months
  
• acute pain r/t abdominal distension aeb complaints of back pain[other symptoms of pain]
  
• deficient knowledge, post op expectations r/t lack of information aeb [symptoms of patient's lack of what is expected of him post operatively]
  
• risk for infection r/t invasive procedures [picc line, ng tube]
  
• risk for injury r/t immobility [dvt, pneumonia, skin break down]