Need help with primary nursing diagnosis

Nursing Students Student Assist

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88 year old F patient was admitted with Acute Lower GI Bleeding. My nursing care book and Lippincott have diagnosis's for upper GI bleeding but not lower.

The Dr. ordered a colonoscopy for tomorrow thinking she has an ulcer.

Her other pertinent medical diagnosis are dimentia and hrpernatremia.

She was admitted with a low BP 104/69 and is incontinent.

She states she feels fine but her daighter was the one who reported the bleeding from rectum.

Any insight into a primary nursing diagnosis will be greatly appreciated. I did good on my acute renal failure care plan but this one has me stumped since my books lack specifics for LOWER Gi bleeding.

Thanks in advance.:bow:

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Hi! I am a fellow nursing student - so take my advice with a grain of salt!!! :D I also have a patient with GI Bleeding, but his is due to e/g varices. I am doing my nursing diagnosis on the symptoms like fluid volume deficiency due to blood loss and diarrhea.

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

care plan books are only good in helping with commonly encountered medical problems. if you fail to learn how to develop a care plan from scratch and depend on copying them from care plan books, you will delay in learning how to think critically. you need to use the nursing process to solve this dilemma. this is how the nursing process is used to 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)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 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 - look up information about gi bleeding and what the signs and symptoms are. lower gi bleeding in the small intestine is very difficult to diagnose, let alone find. if a lesion or polyp in the colon can be identified--great. however, i was a med/surg nurse for many years and saw lots of patients who came in with a diagnosis of unknown site of gi bleeding for transfusion after transfusion with their only symptoms being low h&hs. my oncologist says that cancer in the small intestines is rare, but it does occur. irritable bowel syndrome and crohn's disease can also cause some gi bleeding in the small intestines. the result is signs and symptoms of blood loss anemia. you also should look up the signs and symptoms of dementia and hypernatremia. since the patient is having a colonoscopy there will need to be a bowel prep. don't forget to check the complications of these things.

  • medical conditions
    • lower gi bleeding
    • rule out ulcer
    • dementia
    • hypernatremia

    [*]medical treatments

    • colonoscopy tomorrow

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is all the data you provided. what were the symptoms of the dementia? any symptoms of anemia? what kind of incontinence did this patient have: bowel, bladder or both? is the skin at risk of breakdown as a result of the incontinence? since this patient has dementia, are there problems with accomplishing adls or mobility?

  • incontinent
  • bleeding from the rectum

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -

  • deficient fluid volume
  • bowel incontinence/total urinary incontinence

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To the OP I notice you threw in a lot of doctors diagnosis in the mix. Their diagnosis is a good way to see what direction youre going but focus more on the patient, and the patients needs. Also keep in mind what you as a nurse can treat, and everything should be clearer to you

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I have a patient that has hepatic hypertension causing E/G varices, hepatic encephalopathy, protuberant ascites with fluid wave and + 1 edema in his hands and feet. What can I do for a pt teaching nursing diagnosis? His family has not been available except by phone. Would you pretend to teach the family? Also, many of the things I would normally do, they are not doing because his liver failure is so advanced. For example, he has significant fluid deficit with concentrated yellow urine, dry mucus membranes and slack tugor, BUT they are restricting his fluids to 50 ml in his IV PGBK, the fluid you need for NG tube medication and oral care on a stick sponge. I am doing stuff like comfort measures with lotion and oil, monitoring IO, daily weight ect, but can't directly fix the problem. What do you suggest?

Also, does Jaundice have a ND?

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Specializes in med/surg, telemetry, IV therapy, mgmt.
i have a patient that has hepatic hypertension causing e/g varices, hepatic encephalopathy, protuberant ascites with fluid wave and + 1 edema in his hands and feet. what can i do for a pt teaching nursing diagnosis? his family has not been available except by phone. would you pretend to teach the family? also, many of the things i would normally do, they are not doing because his liver failure is so advanced. for example, he has significant fluid deficit with concentrated yellow urine, dry mucus membranes and slack tugor, but they are restricting his fluids to 50 ml in his iv pgbk, the fluid you need for ng tube medication and oral care on a stick sponge. i am doing stuff like comfort measures with lotion and oil, monitoring io, daily weight ect, but can't directly fix the problem. what do you suggest?

also, does jaundice have a nd?

what can i do for a pt teaching nursing diagnosis. . .would you pretend to teach the family?

that would be dishonest, wouldn't it? assess the patient's teaching needs. there are several ways to diagnose and handle a learning need.

. . .many of the things i would normally do, they are not doing because his liver failure is so advanced.

this sounds like a learning need.

also, does jaundice have a nd?

jaundice is a
medical diagnosis
. nursing diagnoses are based upon patient symptoms and abnormal data (see my other post above) and have little relationship to medical diagnoses.

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How do I teach a comatose patient?

This is a care plan for an assignment, not something I will actually do with a patient. In "the real world" I would not have the artificial requirement of one teaching, one risk, 6 actual- I would just make the nd's base on the patients true needs.

It is hard to know the difference between medical diagnosis and symptoms. His official medical diagnosis is hepatic hypertension, hepatic encephalopathy, cirrhosis and Hepatitis C. So things I observe- jaundice, ascites, edema are also his medical diagnosis?

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