POC for a few nursing diagnosis

[Marysworld38]

I am a 2nd year nursing student developing a plan of care that my instructors will enjoy ripping apart. I have 3 top nuring diagnosis to have an outcome, supporting data, interventions and evaluation and changes to come up with for the 3 ND's.

1. Dysfunctional Gastrointestinal motility R/T intestinal obstruction AEB client's last BM was 9 days ago.

2. Impaired urinary elimination R/T urethral inflammation AEB insertion of a foley catheter due to the absence of urinary output for 24 hours.

3. MY INSTRUCTOR TOLD ME TO USE THIS ONE- IT's NOT IN MY NANDA BOOK!!! Risk for SIRS/sepsis (systemic inflammatory response syndrome) R/T immune system response to surgery. That one doesn't even sound right to me. Would the supporting data and interventions be similar to risk for infection????

My confusion is with client outcomes that are measurable in the 1 day of care I had this patient and supporting data specific to each ND, and interventions that are appropriate.

For starters, are these well worded diagnoses??? And any info that may assist with the rest would GREATLY be appreciated.

Thanks, I love this site. I use it weekly and often several times a week. The books don't really tell the whole of the reality of nursing.

Client 62 yr old female- admitted 4 abdominal pain- emergent surgery for inguinal hernia repair, ended up with 20 cm necrotic small bowel resection. 4 days post op- with no BM and no urine output until cathed. Normal weight. NPO until NG suction is removed. Meds- PCA morphine, Zofran, CBC indicates some type of (hemolytic???)anemia & leukocytosis. BMP- electrolytes WNL except elevated glucose. Urine albumin, blood, WBC all elevated. They are doing a test to assess for paralytic ileus but I will not have outcome of test result.

Any suggestions on this POC would be much needed and extremely appreciated.

[nurseprnRN, BSN, RN]

nobody's gonna have much in the way of bm post bowel resection, especially if they've been npo she might not be obstructed, but she might have other reasons to have decreased mobility-- maybe she necrosed some more bowel or has a postop ileus.

i'd say, "dysfunctional gastrointestinal motility r/t recent resection surgery aeb (how do you know something is wrong in there?--- high ng tube output, no rectal output, absent bowel sounds, nausea/vomiting.... you get to say how you know.)

" impaired urinary elimination r/t urethral inflammation aeb insertion of a foley catheter due to the absence of urinary output for 24 hours."-- i have to say, this lady sounds sick enough that i'd be worried about her renal function (maybe prerenal-- low bp intraoperatively? dehydration? relative hypovolemia from sepsis?) being too lousy to make urine. how much did they get out of her when the cath went in-- lots and lots (retention) or not so much (oliguria)?

i don't think you can attribute failure to produce urine to urethral inflammation without better evidence-- putting in a foley isn't really evidence, is it? how are her renal labs? if they are lousy, why? (i&o, perfusion, sepsis...check it out.) if they are all ok, and she's making and has made good pee, what other things can cause urinary retention? (drugs...?)

i actually agree with your instructor on the last one. necrotic bowel is nothing to sneeze at. noodle around in the literature and see what you can learn about that, and about inflammatory response. it could surprise you and lead you down some scary paths, all requiring great nursing assessment and intervention.