need help with nursing dx...

Daytonite, BSN, RN · Jun 22, 2009

now, i know you've seen my posts a lot on the student forums. follow the nursing process to figure out the possible nursing problems going on here even though you haven't even seen this person yet. this lady is basically being worked up by her doctor to discover what the rectal bleeding is all about. rectal bleeding can be due to hemorrhoids, abscesses, polyps or neoplasms, colitis, diverticula, a foreign body or an endocrine disorder. the colonoscopy is being done to reveal if any of those conditions are present. at her age, keep your fingers crossed because the likelihood is that it is either hemorrhoids or cancer. the elevated monocyctes alone are inconclusive for infection. she did have hip and knee replacements without mention of oa which seems a little unusual. a sedimentation rate would be a better test to reveal an infection.

step 1 assessment - 86 year old female admitted for rectal bleeding with a history of htn, elevated cholesterol, hypothyroidism, has a pacemaker (why?), history of utis, incontinence, and r hip/bilatateral knee replacements. is on medication for hypertension (lisinopril, amlodipine), gerd which wasn't mentioned in her h&p (omeprazole), and an antidepressant which also wasn't mentioned in her h&p (sertraline). her blood counts are slightly decreased which they tend to be in the elderly. medical interventions include a clear liquid diet and continuous infusion of 0.9% nacl @ 70ml/hr. probably as preparation for the colonoscopy tomorrow. (http://www.surgeryencyclopedia.com/ce-fi/colonoscopy.html) it is interesting that she is hospitalized and has an iv. i wonder if her doc feels she is dehydrated. colonoscopies are usually done on an outpatient basis. maybe she doesn't have anyone to drive her to and from the procedure so she had to be hospitalized. he has also ordered brp w/assist (not unusual for an 86 year old with hip and knee replacements) and a foley for her incontinence.

step #2 determination of the patient's problem(s)/nursing diagnosis -

deficient knowledge, bowel preparation for colonoscopy r/t lack of information
risk for falls r/t elderly age, anemia, history of knee and hip prostheses, on antidepressant and antihypertensive medication

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imbalanced nutrition: less than body requirements

there really is no evidence of this.

impaired urinary elimination

how can we treat incontinence that is being treated by the doctor with a foley catheter?

shrimpchips, LPN · Jun 23, 2009

That makes sense about the urinary incontinence, but I guess what confused me was that under the nursing interventions tab, it said that she is refusing a foley catheter but then it also said "foley catheter straight drain" - as in a straight cath?

Thank you for your help! Formulating a nursing diagnosis is still something that I need to get a grasp on - I don't know why it is so difficult!

Daytonite, BSN, RN · Jun 23, 2009

"foley catheter straight drain" sounded to me like a foley catheter to straight (gravity) drainage. If she doesn't have a catheter in, the she would probably be incontinent, especially with an IV running. They are going to be giving her something to clean her colon out for the colonoscopy this evening and then in the morning, so she is definitely at a risk for falling because she is going to be in the bathroom a lot (I have a colonoscopy about 3 times a year). Seeing as not much information is known I would probably go with Risk for Urge Urinary Incontinence R/T effect of IV fluids if you want to address that, but I like the other two that I came up with already.

I suspect she is just there for testing.