Medical Diagnosis/Pathophysiology/Signs and Symptoms Help

[jaymay588]

A friend of mine in clinicals this week was assigned a patient who is about to undergo an ileostomy reversal (closure or takedown). That is the only reason the patient is in the hospital. We both are trying to brainstorm as to what to put for a medical diagnosis, the pathophysiology and the sign and symptoms for the medical diagnosis but unfortunately we are both struggling with it. The nursing diagnosis, goals and interventions are pretty standard based on lab work and post-operative care but can you put a ileostomy reversal as a medical diagnosis? It's not in either volumes of our med-surg books. If you could help I'd really appreciate it. Even if it's just hints or tips to lead us in the right direction. Thanks so much for your help!

[nurseprnRN, BSN, RN]

sure you can. it's a surgical procedure, so you can anticipate many of the same assessments and interventions as for any abdominal surgery.

again, there is no list of column a = medical diagnosis, column b = nursing diagnosis. nurses make diagnoses based on their assessments. in your case, your assessment will include learning as much as you can about surgery, specifically abdominal surgery, and surgical complications.

[JROregon, ASN, BSN, RN]

Well, that wouldn't be a medical diagnosis. What caused the need for the surgery in the first place? Was it Crohn's, ulcerative colitis, cancer? See if you can find it in the medical history. That would be the medical Dx.

[JROregon, ASN, BSN, RN]

GrnTea is probably right about what you should focus on : )

[Double-Helix, BSN, RN]

The correct term for the procedure is reanastamosis. So the patient's diagnosis would be status post small bowel reanastamosis.

In terms of your nursing diagnoses, think about the procedure. The patient is having bowel surgery. An incision is being made in the abdomen and then the intestines. The bowel is by no means a clean organ, so what does bowel surgery put the patient at a high risk for?

Any time the bowel is manipulated, paristalsis usually stops for awhile. This can be up to several days. So in that time, the bowel isn't working. What diagnoses can you think that might relate to an inactive bowel?

After a bowel surgery, the patient usually has an NG tube. Since the bowel isn't working, the patient can't eat anything. What might this place the patient at risk for?

(I see know that you said you didn't have a problem with the nursing diagnosis, but I've already typed this so I'm just going to leave it.)

The pathophysiology is going to relate to the patient's underlying condition. Why did they have to have to ileostomy in the first place? For signs and symptoms you can list the signs and symptoms of their initial condition and explain how they have resolved. How did the surgeons know that the patient was ready to be reanastamosed?

[xtxrn, ASN, RN]

The doctor should give the medical diagnoses :)

Nursing diagnoses are based on your assessment and knowledge of the medical diagnoses, and the procedures. Even the same medical diagnoses and procedures will have differences between patients based on the information YOU find out when you assess the patient- physical and psychosocial/spiritual issues are included in nursing diagnoses. :)