cld1217

Thank you!

I remember seeing on the chart that he had pain 0/10 the past few days, so i didn't see that as a current issue. However, i am not sure if disturbed body image is or not. He has a hx of depression, although, i figured other diagnoses were higher priority than emotional stability?

Thank you so much! I confirmed after reading your comment that i did not get enough information at the hospital when i went. i didn't look at I&O. i didn't record VS. The only thing i remember now, is that he had a pain of 0/10 for the past few days, so i knew pain wasn't a current factor. But you definitely helped fill in some blanks for me. We have a graphic analysis for our nursing diagnoses and it only has 4 spots, but your right, i could do more.

Case: -Med Dx- Colovesical fistula (post low anterior resection for rectal cancer) i.e. hole between colon and bladder -partial/end colostomy performed -PICC; NPO, Feeding tube c enteral feeding cont 24h & free h20 q4h; 2L NC -LESIONS: pressure ulcers (L heel, coccyx) & L/midline abdomen & L LE wounds (c wound vac) -LABS: INCREASED (na, chloride, glucose, BUN, creatinine, Alk ph, CK total/MB, total bili, PT, pH, WBC count, Neutrophils, urine (blood, protein, urobilinogen, nitrites, leukoctyes, bacteria) DECREASED (O2 sat without NC, PCO2, Ca, total protein, albumin, prealbumin, INR, RBC, Hgb, Hct) NEED: TOP 4 nursing diagnoses; Possible options?: Risk for infection R/T recent invasive prodecure, multiple skin lesion, bacteria in urin, and increased WBC count. Risk for deficient fluid volume R/T deviations affecting fluid absorption, hypermetabolic state increasing fluid needs, and increased wound drainage Impaired skin integrity .... Risk for ineffective gastrointestinal tissue perfusion ..... ? Imbalanced nutrition: less than body requirements R/T high metabolic needs, decreased ability to ingest/digest food ?? Ineffective breathing pattern ...? Risk for dysfunctional GI motility R/T abdominal surgery, immobility ?? I don't feel very confident about these, and could use some advice/suggestions (since this is due tomorrow morning)! I am struggling with prioritization too! Thank you :-)

For some reason it is hard for me to prioritize the diagnoses. i know it goes ABC's then Pain, but when your pt doesn't have problems with any of those things, then i get stuck. And now i'm wishing i would have gotten more information on my pt before i left the hospital i.e. on his breathing, etc. to see if i can even use "Ineffective breathing pattern", because all i know is that he is on 2L NC becuase his O2 sat was a little low. BLAH. Sometimes this is just frustrating.

Case: -Med Dx- Colovesical fistula (post low anterior resection for rectal cancer) -partial/end colostomy performed -PICC; NPO, Feeding tube c enteral feeding cont 24h & free h20 q4h; 2L NC -LESIONS: pressure ulcers (L heel, coccyx) & L/midline abdomen & L LE wounds (c wound vac) -LABS: INCREASED (na, chloride, glucose, BUN, creatinine, Alk ph, CK total/MB, total bili, PT, pH, WBC count, Neutrophils, urine (blood, protein, urobilinogen, nitrites, leukoctyes, bacteria) DECREASED (O2 sat without NC, PCO2, Ca, total protein, albumin, prealbumin, INR, RBC, Hgb, Hct) NEED: TOP 4 nursing diagnoses; Possible options?: Risk for infection R/T recent invasive prodecure, multiple skin lesion, bacteria in urin, and increased WBC count. Risk for deficient fluid volume R/T deviations affecting fluid absorption, hypermetabolic state increasing fluid needs, and increased wound drainage Impaired skin integrity .... Risk for ineffective gastrointestinal tissue perfusion ..... ? Imbalanced nutrition: less than body requirements ... ?? Ineffective breathing pattern ...? Risk for dysfunctional GI motility ...? I don't feel very confident about these, and could use some advice/suggestions! Thank you :-)