need help coming up with a nursing dx for my patient

[tazzie1991]

I have an 86 yo with HTN, rectal cancer, arthritis, aortic stenosis, swollen scrotum. His admitting dx was rectal cancer. He had surgery about two weeks ago and has an ileostomy and foley cathether right now. I was going to use ineffective tissue perfusion r/t ileostomy. Please help with the care plan for that or if you think i should use something that might suit this client better. Thanks.

[heavensent88_RN]

My opinion:

Recent Assessment of patient will help you come up with a nursing diagnosis and nursing care plan for your patient. Subjective and Objective data is important... what is you patient's complain? what is he feeling right now?

[tazzie1991]

i did his assessment on thursday night and i need the care plan by tonight because i do my clinical tomorrow

he had pain of two in abdomen, it was distended, his scrotum and member where swollen and they tried for over 1/2 hour to get the foley in then the urologist came in and got it in so i think he was in pain from that too. He has an NGT and is NPO. His mouth and lips were dry he was alert and oriented, had an incission on abdomen with staples with a little erthymea, no edema present, bowel sounds were heard, had ileostomy, foley cathether, was coughing up sputum which was normal. Can ambulate with assistance. Not sure if i should do skin integrity instead of tissue perfusion. Thanks.

[Daytonite, BSN, RN]

diagnosis is based upon doing an assessment of the patient and then making some educated decisions. we follow the same process to get to a nursing diagnosis that doctors follow to get to a medical diagnosis. the difference is that (1) the data that goes into our assessment is a bit different, and (2) our nursing diagnoses are much different in definition and classification than medical diagnoses are.

we use a tool called the nursing process to help us out here. specifically, steps #1 and #2 are needed in diagnosing. i have to use the information you provided. . .

step 1 assessment - assessment consists of:

• a health history (review of systems) - this is an 86 year old man who was admitted with rectal cancer and had ileostomy surgery two weeks ago. he also has htn, arthritis and aortic stenosis
  
• performing a physical exam - your physical exam information is that he is coughing up sputum, has an incision on his abdomen with staples with a little erythema, has pain of 2/10 in his abdomen, his abdomen is distended, scrotum and member are swollen, and his mouth and lips were dry. are you aware that the presence of an ngt is a foreign body? our systems detect that and evoke the inflammatory response and attempt to fight it off. thus, the patient's throat will become irritated and produce all kinds of mucous. this same inflammatory response is going on because the surgeon cut into this man's body and did all his cutting and rearranging down in the abdomen and pelvis. it is partly responsible for some of that abdominal distension and scrotal and penile swelling. once the intestines are touched by human hands peristalsis shuts down and all activity in the bowels comes to a standstill. fluid and gas accumulation result and the patient's abdomen becomes distended and they get nauseated. that is why the doctor ordered the patient to be npo and have the ngt, although for two weeks out from the surgery peristalsis should have restarted by now. so, you should be checking out why that hasn't happened.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no adl assessment is present except that he can ambulate with assistance (no specifics about what kind of assistance is needed).
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - since this man has rectal cancer, htn, arthritis and aortic stenosis these conditions should be looked up and their pathophysiologies noted as well as their signs and symptoms. the pathophysiologies will be needed for the etiologies on some of the nursing diagnostic statements. the signs and symptoms should be compared with what you saw during your physical exam of the patient to see if you missed seeing something. this is how you will improve your assessment skills.
  
  • http://www.cancer.gov/cancertopics/wyntk/colon-and-rectal - what you need to know about colon & rectal cancer
    
  • http://www.surgeryencyclopedia.com/fi-la/ileostomy.html - ileostomy (the surgery)
    
  • http://www.merck.com/mmpe/sec07/ch071/ch071a.html - hypertension
    
  • http://www.merck.com/mmpe/sec07/ch076/ch076c.html - aortic stenosis
    
  • http://www.merck.com/mmpe/sec04/ch034/ch034e.html - osteoarthritis
    

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - these are treatments: ileostomy, foley catheter, ngt, being npo

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - all the above data can be put together to form a logical story of what is going on. it can all be reduced to a list of abnormal data that we can work with. we need what will become the signs and symptoms of our nursing problems, so we begin to make a list of them. from what you posted, i have. . .

• coughing up sputum - needs better description
  
• had an incision on abdomen with staples with a little erythema - needs better description
  
• pain of 2/10 in abdomen
  
• abdomen was distended
  
• scrotum and member where swollen
  
• mouth and lips were dry
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match this abnormal assessment data to nursing diagnoses

• ineffective airway clearance r/t foreign body in airway aeb coughing up sputum
  
• excess fluid volume r/t inflammatory response secondary to surgical tissue trauma aeb distended abdomen and swollen scrotum and member
  
• acute pain r/t surgical invasion aeb abdominal pain of 2 on a scale of 0 to 10.
  
• impaired tissue integrity r/t surgical invasion aeb incision on abdomen with staples and a little erythema
  
• impaired oral mucous membrane r/t presence of ntg and being npo aeb dry mouth and lips
  
• deficient knowledge, ileostomy care r/t lack of knowledge aeb [to be established]
  
• risk for infection r/t traumatized tissue following foley catheter insertion
  

until you know more about the ileostomy and why this man is still in the hospital (he's been there a long time post-operatively) that is what i would diagnose from the information you gave. without further information i hesitated to diagnose anything more pertaining to the colostomy. i suspect there are also self-care deficits, but no information was provided about them. also, a diagnosis of delayed surgical recovery may be called for here, but not enough information is posted to determine that.