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Discussion

Nursing care plan assignment -- looking for help w/ diagnosis

Here's the assessment:

62 year old male - Hx of HTN - Hx of coronary artery disease - CABG 6 days ago - incisions present with staples at sternum and left and right saphenous veins- incisions well approximated with no redness, drainage, swelling or foul odor - VS stable: 0800 B/P 122/78, P84, R20, T98.8 - lungs clear in all fields on auscultation - O2 @2L/min N/C prn - WBC count 10,200 - incentive spirometer q2h - 1+ edema to ankles and feet bil. - pedal pulse strong and regular - bowel sounds x 4quads hypoactive - last BM 3 days ago, small brown formed - passing flatus - eating average of 50-75% of a regular diet - ambulating 50 ft with assist x1 - reports pain in incisions 2/5 - "I'm glad that my wounds are healing well" - "I don't have any trouble breathing" - "I only coughed when I woke up this morning; my sputum was white with a little bit of blood"

I need to formulate just one nursing diagnosis. I like Delayed Surgical Recovery r/t Extensive Surgical Procedure because of the defining characteristics loss of appetite, report of pain in incision, CABG 6 days ago. However, I don't like it because the report of blood in white sputum isn't addressed, but I can't seem to find a diagnosis that meets those other abnormalities.

Maybe Ineffective Airway Clearance r/t presence of artificial airway. He's obviously receiving oxygen and using an incentive spirometer, so he does have some lung issues, yet his vitals are good, although R20 is on the higher end of the normal averages.

Can anyone help me? Am I missing something? Faulty thinking?

Thanks :D

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    The wbc count is high which means he may have an infection. You would want to watch that as well as his temperature for elevation. The respiratory rate might also be elevated in the case of infection.

    It doesn't appear he's in respiratory distress as his lungs sounded clear on ausculation. He's not on O2, it's PRN in case he needs it.

    His bowel sounds are hypoactive and he hasn't had a bowel movement in 3 days. So you could put constipation which could be related to pain medications he's on (opiates) or due to the anasthesia being very slow to wear off, but that isn't stated in this example.

    Also he's not eating very much, which could lead to a nutrition imbalance.

    The sputum is important and you would of course want to get it tested but I'm not sure of a nursing dx for it.

    The slight swelling is probably from his bad ticker. Monitor that to make sure it doesn't get worse.

  • Quote
    Here's the assessment:

    - bowel sounds x 4quads hypoactive - last BM 3 days ago, small brown formed - passing flatus -

    Can anyone help me? Am I missing something? Faulty thinking?

    Thanks :D

    I'd go with constipation

    Constipation r/t decreased peristalsis secondary to immobility AEB decreased bowel sounds and hard, formed stools.

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