Nursing prioritisation

[utssyd84]

Hi all. I hope someone can help me with this.

Im working on an assignment to prioritise nursing care to a patinet who has a abdominoperineal resection. He was not eating well. Low HB of 80, low calcium amd magnesium. No signs of potaassium imbalance. Has asthma and dehydrated. He is in pain. Has a perineal drain, stoma, IDC, and IVC insitued. Now my nursing diagnosis that i have placed are 1. Ineffective airway clearance, second is deficient fluid volume and for my third one (in priority order i dont know whether to put risk of infection OR imbalanced nutrition: less than what the body requires. I will really appreciate your help.

Many thanks in adavnaced

[Daytonite, BSN, RN]

when you sit down to write a care plan the one thing you should do is follow the steps of the nursing process. it will help you organize your critical thinking. so, what i did was take the information that you supplied and do just that. some very interesting things emerged that i think you missed by not doing this.

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 - know about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. - the complications of anesthesia include breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism), hypotension (shock, hemorrhage), thrombophlebitis in the lower extremity, elevated or depressed temperature, any number of problems with the incision/wound (dehiscence, evisceration, infection), fluid and electrolyte imbalances, urinary retention, constipation, surgical pain, and nausea/vomiting (paralytic ileus) and they need to be monitored for.

• asthma - what symptoms of this does the patient have?
  
• dehydration - what symptoms of this does the patient have?
  
• medical treatments:
  • abdominoperineal resection - why was this surgery done?
    
  • perineal drain - what kind of care is being done for this?
    
  • stoma - where is this located and what is being done for this?
    
  • idc - what is this? and what is being done for it?
    
  • ivc - what is this? and what is being done for it?

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• not eating well
  
• pain - describe the location and intensity of the pain
  
• low hb of 80 (is this heart beat or hemoglobin?)
  
• low calcium
  
• low magnesium

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 - in order of maslow's hierarchy of needs

• imbalanced nutrition: less than body requirements r/t surgical intervention and inability to digest food aeb not eating well, low calcium level and low magnesium level. [physiological need for food]
  
• acute pain r/t surgical intervention aeb (pain - describe the location and intensity of the pain) [physiological need for comfort]
  
• impaired skin integrity r/t surgical intervention aeb [description of wound, stoma and drains] [safety need for protection]

your diagnoses included the following, but i do not know how you reasoned them:

ineffective airway clearance

the problem i have with this diagnosis is that there is no evidence to support using it in any of the information you posted.

ineffective airway clearance

has to do with the

inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

(page 5,

nanda-i nursing diagnoses: definitions & classification 2007-2008

). there is no evidence that this patient has a productive cough, rales, rhonchi or wheezes, or dyspnea, so you can't use this diagnosis.

deficient fluid volume

the fact that the doctor diagnosed the patient with dehydration isn't enough to assign this diagnosis. you still have to show that the patient has the evidence of dehydration. break the dehydration down into its signs and symptoms. does your patient have any of them? the nanda taxonomy for this diagnosis includes a list of the symptoms (defining characteristics). you can see the list on this page:

deficient fluid volume

. what is causing the dehydration? you need to know for the related factor of your diagnostic statement.

risk of

infection

(r/t invasive surgical intervention)

yes, this can be used. it would be an anticipated complication of the surgery: a wound infection. it goes at the end of the list of diagnoses because it is not an actual problem. see this post on how to se up the interventions for this kind of diagnosis:

https://allnurses.com/forums/2751313-post8.html