nursing dx for foreign body ingestion

Editorial Team / Admin · Oct 23, 2016

The goal of nursing diagnosis is to look at the nursing assessment of the patient. Sometimes, the assessment shows needs that are not related to the medical diagnosis, and that's perfectly fine. What does your patient's nursing assessment tell you are the priorities?

ukade · Oct 23, 2016

This helps a little, but because there's not much going on with this pt, it's hard to distinguish what is the priority. Assessments are all okay except for a little things like high bp, I&Os are not completely balanced, lung sounds are clear on one side diminished on another. In his case, I'll probably focus more on possible fluid imbalance but I'm not allowed to use risk for dxs. Would slight fluid imbalance without s/s be more of a priority than knowledge deficit?

I feel that knowledge deficit is probably more of a priority since the foreign body was accidentally swallowed pt will need to learn to chew well. Pt's diet will change for awhile too, but right now pt doesn't get to eat for awhile, so teaching at this time is not the best time. I'm so confused now.

Also, another question, for perceived constipation would this make sense:

Perceived Constipation r/t hypoactive bowel sounds as evidenced by Pt expresses worries about constipation pain.

Can perceived constipation be used this way if pt has already had constipation?

I know perceived constipation is used as a dx if pt is always using laxatives and enemas when they don't need to. But if the pt, is not actively doing anything about possible constipation, then should it not be a priority?

Esme12, ASN, BSN, RN · Oct 23, 2016

I'm having trouble coming up with a nursing dx for my pt who is an adult, not a child who had GI surgery due to foreign body ingestion.
I have acute pain as a definite.
I also have perceived constipation, but I don't think this is a correct dx for this pt.
I have knowledge deficit, because pt will need to learn about how their nutritional diet is going to change. I don't know if there is another Nursing Dx that is more appropriate for what I am going for though.
Please help, do these dxs sound good?

What semester are you? What care plan books do you have?

Care plans are like the recipe card to care for your patient. Your care plan should be based off of your assessment. Care plans are all about the patient and the patients problems. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT... la9MFCKoIaKIlaHjVuttgx238A8l+oISTPknrAAAAAElFTkSuQmCC

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Now...tell me about your patient.

Esme12, ASN, BSN, RN · Oct 23, 2016

This helps a little, but because there's not much going on with this pt, it's hard to distinguish what is the priority. Assessments are all okay except for a little things like high bp, I&Os are not completely balanced, lung sounds are clear on one side diminished on another. In his case, I'll probably focus more on possible fluid imbalance but I'm not allowed to use risk for dxs. Would slight fluid imbalance without s/s be more of a priority than knowledge deficit?
I feel that knowledge deficit is probably more of a priority since the foreign body was accidentally swallowed pt will need to learn to chew well. Pt's diet will change for awhile too, but right now pt doesn't get to eat for awhile, so teaching at this time is not the best time. I'm so confused now.
Also, another question, for perceived constipation would this make sense:
Perceived Constipation r/t hypoactive bowel sounds as evidenced by Pt expresses worries about constipation pain.
Can perceived constipation be used this way if pt has already had constipation?
I know perceived constipation is used as a dx if pt is always using laxatives and enemas when they don't need to. But if the pt, is not actively doing anything about possible constipation, then should it not be a priority?

How old is this patient? What was the foreign object that he swallowed? What was the surgery done? Is the patient NPO? Does the patient have a NG? DO they have an IV? How many days post op? DO they have bowel sounds? Why do they have an elevated B/P? DO they have a foley? How do you know the I/O are not balanced?

Tell me your assessment. Is perceived constipation a NANDA diagnosis? If the definition says use/abuse of laxatives then this does not apply to this patient.

ukade · Oct 23, 2016

Thank you for your input, I'll try listing out all of his assessments that stand out to me and then go from there.

Basically pt had part of his stomach removed because a metal shard was embedded in the stomach wall (Billroth II). Pt can accomplish ADLs on their own, min assist. Pt has no foley, but is NPO and does have ng tube and IV fluids. Output is -1000mL over 3 days. Bowel sounds were hypoactive. HBP is something Pt already had. POD 3.

Since Pt is NPO, has IV fluids, risk for fluid imbalance should be one of the concerns, but I can't use a risk for diagnosis and Pt does not have significant evidence for deficient fluid volume. However, this is something that might affect gastrointestinal motility.

BirkieGirl · Oct 23, 2016

hydration, pain control, elimination, nutrition. I had part of my stomach removed and FYI- patients with gastrectomy can't eat any actual food for a few weeks. it's basically liquids, then full liquids, then VERY soft/mushy food, then soft food, then finally at week 4 there is some semblance of real food. look at your assessment then consider the steps you need to take for appropriate diagnosis. NIC & NOC were my best friends early in nursing school 25 years ago! Good luck!!!