HELP PLZ: Nur Dx for Colovesical Fistula, Colostomy Pt

[cld1217]

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?:

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 R/T high metabolic needs, decreased ability to ingest/digest food ??
   
6. Ineffective breathing pattern ...?
   
7. 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]

what about:

disturbed body image

acute pain

[cld1217]

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]

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!

[cld1217]

Thank you!