Help understanding a diagnosis

Nursing Students Student Assist

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I just got my patient assignment for in the morning. I need to write up a clinical prep with the patients diagnosis, a brief discussion of it (disease process, S/S, causes, possible complications, etc.) - a definition of the current surgery (if applicable) and 5 activities of nursing care - prioritized acc. to Maslow's.

Problem is, I'm a little unclear just what the diagnosis is, mostly because of how it is written. It's a new semester with a new clinical instructor, who isn't available for questions except during clinical hours.

So, here's what's written: 2/9 abdominal pain (ileus) status post laprascopic cholecystectomy 2/4/10.

I'm thinking the numbers are dates - the first one admission - the last one, date of surgery, since it says "post laproscopic cholecystectomy" (I'm thinking the patient went home & was later readmitted because of the pain)???

As far as admission diagnosis - abdominal pail (ileus) - could that mean pain r/t paralytic ileus, or possibly abdominal pain they think is ileus?

And status - does that just mean the patient is post-op?

Any help would be greatly appreciated. In the meanwhile, I'm going to start writing up a "brief discussion" of ileus & a description of a cholecystectomy & hope I'm focusing on the right things.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

do you have to state what the medical diagnosis is, or the nursing diagnosis? the medical diagnosis is surgical ileus secondary to a laparoscopic cholecystectomy. this is a complication of surgery. the nursing diagnosis would be acute pain r/t abdominal distension or abdominal pressure.

post- is medical terminology that means "after". when combined with "status" it means "condition after". it is usually abbreviated as "s/p" and used with procedures, as is s/p laparoscopic cholecystectomy or s/p hysterectomy.

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