Post Op FESS Patients

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hi. i'm an incoming 2nd year nursing student, and i just finished my pre-clinical duty at the hospital. as a part of our requirement, we are asked to submit the nursing process, and two nursing care plans; actual and potential. i have already interviewed my patient and got some information. but, it does not seem enough. i need help in conducting this. i'm scared to make a mistake. :imbar

here is the information:

female patient, 22y/o,ht: 5feet and an inch, wt: 38kg. she was admitted to the hospital for operation,fess (functional endoscopic sinus surgery). she just got operated yesterday, may20,2009, at 1pm-8pm. when i interviewed her, she said that she had the sinusitis since elementary. it was only last 2007 that the child of her boss found some nasal polyps. he adviced the client to have a check up with the ent. it is this year that her boss told her to get her sinuses operated. as of now, she is currently a post operative patient. her record shows that she has allergic rhinitis, and that 2 years prior to admission, she has been having yellowish discharge with no foul smell. she sometimes complains about severe headaches, from the frontal sinus to the top of the head. the actual diagnosis that i can see now is allergic rhinitis (caused by pollution and some food). i was thinking of difficulty of breathing (her nose is covered and has wounds still from the operation) for her potential diagnosis.

i really really really need help for this. i will be grateful if you give me some pointers for this one.

if you want more information, please do not hesitate to pm me. thankyou. :)

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the only things i can find are:

ineffective airway clearance r/t obstructive sinuses

knowledge deficit r/t post operative self-care

risk for aspiration risk factors postoperative drainage

risk for infection risk factor invasive procedure

pain r/t surgical trauma?

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CURSEDandBLESSED! Thank you so much! :D VERY HELPFUL. ;) But can you please state which is potential and actual? Thanks so much!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you posted this on the general nursing discussion forum this morning and i gave a rather extensive answer for you complete with two nursing diagnoses, an actual and potential one, and how i got them along with a number of weblinks to information and one specific weblink to encyclopedia of surgery about this procedure and its complications which you needed to know in order to determine potential nursing problems. did you read it? do you have questions? i am always happy to give pointers and help students. was there something you did not understand about my post? see https://allnurses.com/general-nursing-discussion/nursing-diagnosis-post-393806.html

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Hi DAYTONITE! I got your reply to my thread on the General Discussion, I just followed the suggestion of another member, that is to post this on the Students Discussion. Thanks again! :D

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Specializes in med/surg, telemetry, IV therapy, mgmt.

unfortunately, we don't have a nursing case study for you to view, but i tried to give you direction on how to organize your paper in following the steps of the nursing process. a good amount of the beginning of the paper would be taken up with assessment data which i broke down into its 5 components for you. seriously, read the fess page on encyclopedia of surgery. you were correct in that breathing is the actual problem of these patients. the potential problem is related to their vision due to swelling as a result of inflammation or an accidental mistake made by the surgeon. mistakes, however, would be known by the time of discharge. infection is unlikely because the patients are discharged on antibiotics. potential nursing diagnoses always begin with the words "risk for" or "potential for" here in the u.s. there are 2 websites where you can view information for about 80 of the u.s. nanda nursing diagnoses along with some nursing interventions and rationales:

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