Case:-Med Dx- Colovesical fistula (post low anterior resection for rectal cancer) i.e. hole between colon and bladder-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?: Risk for infection R/T recent invasive prodecure, multiple skin lesion, bacteria in urin, and increased WBC count.Risk for deficient fluid volume R/T deviations affecting fluid absorption, hypermetabolic state increasing fluid needs, and increased wound drainageImpaired skin integrity ....Risk for ineffective gastrointestinal tissue perfusion ..... ?Imbalanced nutrition: less than body requirements R/T high metabolic needs, decreased ability to ingest/digest food ??Ineffective breathing pattern ...?Risk for dysfunctional GI motility R/T abdominal surgery, immobility ??I don't feel very confident about these, and could use some advice/suggestions (since this is due tomorrow morning)! I am struggling with prioritization too!Thank you :-)
ser2011 193 Posts Specializes in PCU, Med-Surg/Tele, Psychiatric. Has 2 years experience. Feb 15, 2011 what about:disturbed body image acute pain
cld1217 6 Posts Feb 15, 2011 I remember seeing on the chart that he had pain 0/10 the past few days, so i didn't see that as a current issue. However, i am not sure if disturbed body image is or not. He has a hx of depression, although, i figured other diagnoses were higher priority than emotional stability?
ser2011 193 Posts Specializes in PCU, Med-Surg/Tele, Psychiatric. Has 2 years experience. Feb 15, 2011 Yeah, I was just trying to think up some that would apply that you hadn't posted. Disturbed Body Image isn't a high priority diagnoses compared to Risk for Infection/Ineffective Breathing Pattern and such; but I think it's still important due to the fact that he its going to be living with a colostomy bag hanging off of his side - that's a major life change. As for prioritization, don't forget the ABC's. I think I would reorder the diagnoses Ineffective Breathing Pattern as number one.Good luck!
