I need some help

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I need some help with a nursing DX

for resp. Pt is dx w/ vulvar cancer she had vulvectomy she was 3 days post op so i can not do any dx that are surgical risk.

no Hx of somking, no lung problems Pt not using pain medication she stated she was not in pain

any sugestions

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

read the information on how to write a care plan on this thread:

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Specializes in General adult inpatient psychiatry.

What did you see when you assessed this patient? Anything out of the ordinary in your assessment findings is often cause for a nursing dx. You said in your post what she didn't have, but what about what else you know about this patient?

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well for my project we need 12 Dx form each varable, she has a hx of HTN and gerd and has 2 Jakson Prats that will be left in place after discharge, nothing out of the ordnary is wrong . no pain she is walking on her own , no depression very positive Pt so i am having problems with respiration Dx , nutrition Dx. she is eatign well on her own , no IV all labs normal. its just for this project i have a " healthy" Pt . during assessment she was A&O *3 no edemal normal cap refiill skin turgor less than 2 seconds, lungs were clear , everything was good. if you can think of anythign at all

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

you can't say that any patient who is in the hospital, had surgery and has 2 jackson pratt drains has "nothing out of the ordinary" wrong with them. jackson pratt drains are not normally hanging out of people. i don't have any.

the reason i wanted you to read the information on the assistance - help with care plans thread was so you would learn the sequence of steps to follow in writing a care plan.

  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)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

you are stuck on step #1 - assessment. assessment is a very involved activity that doesn't just mean doing a physical exam of your patient. your physical exam is only picking up actual data from questions you can think of to ask. what about questions you haven't thought of to ask? did you ask this lady what she knew about vulvar cancer and it's treatment? did you ask what she was told her prognosis was? assessment involves:

  • collecting data from medical record - that means reading the doctor's history and physical, doctor's progress notes, consultations, and in this case, the surgical report
  • assess the patient's ability to perform adl's (activities of daily living) - my questions with a vulvectomy would be focused on toileting since i would expect that area of this patient's anatomy to be swollen and sore
  • look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - this information is needed because
    • in looking at and learning about the signs and symptoms of the patient's medical disease, you can double check your own physical assessment and interview information you obtained from the patient to see if you missed something. this is how you will improve your assessment skills.
    • you need to know the etiology (cause) for some of the nursing problems you will discover in constructing your nursing diagnostic statements later
    • http://en.wikipedia.org/wiki/vulvectomy
    • http://www.cancer.gov/ - information on and the treatment for all kinds of the different cancers

you also have a surgical patient here. there are complications of general anesthesia that have to be monitored for several days post operatively--another reason why this patient is still in the hospital. who does that? you, the nurse. here are the complications of general surgery that are probably in your nursing textbook and make some good anticipatory nursing problems:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

when you get to step #2 - problem determination, there aqre not only bursing diagnoses for actual and anticipated problems, but what are called wellness diagnoses for patient's who have absolutely no problems in a certain health area at all. you need a nursing diagnosis reference to find and learn about them.

before i can do anything about suggesting nursing diagnoses for this patient, you have to go through assessment information more thoroughly and come up with abnormal data upon which nursing diagnoses can be based. it's there. you're just not seeing it. that's why you should read an article or two on vulvectomies. look for an article on vulvectomy on the emedicine website (http://www.emedicine.com/). no abnormal data = no nursing diagnoses.

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i have done care plans in the past and i understand how to get Dx i typical map out all my information the way you explain it, i rea that before and that realy helped :). it just with this pt i am having alot of trouble. she was going home with JP my teacher will not let me use any post surgical risk b/c she was going home that day and she was4 days post opp. i did come up with post opp complacations but she doesnt want them. Im sorry its just that i am getting discouraged b/c any post surgical risk she will not let me use. i am not sure that i under stand JP and our nursing book does not have much information on them, just how to empty them maby b/c its a fundmental class (i am not sure)... i am a new nursing stud , why elses would some one be going home with jp i would think you want them to stay in the hosp?

thanks for the help

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sorry i forgot to tell you about assessment data i she was my pt for one day the day she was being discharged. so she has a hx of HTN, she had prn medication primary nurse stated that she had not used in in 2-3 days pt stated she has had no pain and feel good. bun 16,creat 1.1, phosphate 3.7. na,k,mag,glucose all with normal limits.

no smoking or drinking, not over weight

lung and heart sounds normal. no edema caprefill less than2 seconds. pt was walking on her own no cane or walker. she eas able to eat all her food full dite. she takes avapro,verapamil,hctz,omeprazole,

no IVs, equall hand grasp, no jvd. can she be at risk for mobility probles b/c of her HTN, and coudl the indaq tissue prefusion lead to resp problems?, coudl her htn lead to a nurtitional problems?

psychologicaly she is happy,no body distrubuence very nice person,

good hydration. sorry i am trying to think of everything i can :( i just dont know what else, "normal BM", i will keep repling if you have any sugestions

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

This is why you need to look up information about this surgery and see if you can find anything on JP drains. The drains are removing drainage from the surgical area because the tissues were probably pretty well manipulated and cut up during surgery. Pathophysiology of trauma to tissues is that the inflammation response occurs first which is part of the reason all that drainage is happening. Other manifestations of inflammation response are redness, swelling and pain, much of which you won't see, because these organs are internal, but trust me, the swelling is there. The swelling causes pain as the swollen tissues press on nerve endings in the surrounding area. Does the patient know this? Teach her.My mother went home with Jackson Pratts in her mastectomy incisions. The suckers drained for 2 weeks! We had to empty and measure the things 3 times a day. We kept a sheet that I created on the computer to keep tract of this for the surgeon.Your patient would need to be taught how to do the emptying of the drains, how frequently, how to measure the drainage (we used plastic medicine cups and flushed the drainage down the toilet), and to write down the outputs to take to the surgeons appointments with her. Teach her that when the drainage gets to be very scant (5 cc or so) the surgeon will remove the drains by cutting the sutures and gently pulling the drains out--it won't hurt.

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alright, so since she was going home there is nothing i can do about nutrition other thank risk for imbalance r/t s/e of medication. and the jp have no t affect on her rep system do they? could htn affect resp system? i knwo that it affect circulation but its its controled can it affect resp?

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

she should be coughing up gunk from being intubated in surgery. it takes two to three days for the phlegm to loosen up and the patients to start coughing the "good" stuff out. the lungs will almost always be clear, but you have to learn to remember to ask about this coughing. every surgery i've had--and i've had 11--i starting hacking up the thick crap two or three days later. the coughing and deep breathing is just to get the ball rolling. ineffective airway clearance r/t retained secretions aeb cough. anesthesia does a number on people. if you ever have a major surgery then you will understand.

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How about altered body image, griefing, depression?

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