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Discussion

Please help w/first care plan

This is my first care plan (homework assignment) and I am having trouble prioritizing. My instructor is making us list the top two nursing diagnoses for the following assignment:

50 y.o. white female who underwent bowel resection due to cancer.

VS: 150/80;96;28;temp. 100

IV of NS infusing at 75cc/hr

c/o constant sharp pain at operative site - level 8/10; morphine ordered

has large abdominal dressing w/small amt of bright red drainage; drain left in place

foley catheter in place - good urine output

Oxygen is at 2L/min via nasal prongs

has NGT to suction

IV antibiotics q4h

history of smoking 2 packs/day for 40 years

takes meds for hypertension

I have come up with several different diagnoses but I have to list the top two and don't really know how to prioritize. I have come up with acute pain, risk for infection, impaired mobility, impaired tissue integrity. I was thinking i should use risk for infection and acute pain, but wasn't sure if tissue integrity was more important, and just plain don't know which ones are top two.

Please help!

Featured Replies

I've been in your shoes before. Is her Resp 28? That is high normal range is 10-20/min. She is a smoker , on 2L O2 via NC, You may want to check out Ineffective Breathing Pattern. Always remember your ABC A Airway B Breathing C Circulation in priority. If they aren't breathing nothing else matters. We don't really care if she is in in pain if she isn't breathing. So look for ariway problems first and they will be #1, then Breathing problems they will be #2, and then Circulation problems they will be #3, and then safety, nutrition blah blah etc. etc. Hope this helps you.

  • Experts

surgery is a treatment. when a patient has surgery nursing care centers around monitoring for complications as a result of the anesthesia and carrying out orders related to the surgical treatment:

  • complications as a result of the 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
    • nausea/vomiting (paralytic ileus)

    [*]orders related to the surgical treatment

    • morphine ordered
    • iv of ns infusing at 75cc/hr
    • foley catheter in place - good urine output
    • oxygen is at 2l/min via nasal prongs
    • ngt to suction
    • iv antibiotics q4h

you can see that the surgeon is addressing the surgical pain and has ordered morphine, has ordered iv fluids to address fluid imbalance, a foley catheter should resolve any urinary retention, the ngt will keep the stomach empty of secretions so the patient will have no vomitus and iv antibiotics are addressing the potential of infection. what does that leave for us to problem solve (that is what a nursing diagnosis is)?

when a patient has a bowel resection they undergo general anesthesia, are intubated and receive gasses. they are unconscious and intubated for approximately 2 hours for this surgery. this patient has a history of smoking 2 packs/day for 40 years and that is going to make a big difference in her recovery. prior to surgery she would have been instructed in deep breathing and coughing. all patients undergoing general anesthesia are. for a smoker it is even more critical. so, your #1 priority diagnosis isn't even listed. i added it and prioritized your list according to maslow's hierarchy of needs. see http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs there are a few more diagnoses you might want to add.

  1. ineffective breathing pattern
  2. impaired mobility
  3. acute pain
  4. impaired tissue integrity
  5. risk for infection

key thing in prioritizing nds is applying abcs (airway breathing and circulation) and maslow’s hierarchy of needs.

you may also want to purchase a nursing care plan book.

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