What would be my primary nursing diagnosis?

[ShelbySilvertooth]

Patient admitted with bowel obstruction secondary to chronic diverticulitis. He had a right colectomy and a primary anastomosis between the ileum and transverse colon. Pt is a smoker, drinks several drinks on the weekend, has a desk job, and is not active including poor eating habits.

48 hours post-op his morning assessment includes an "okay" O2 stat (not specifically given), R 24, T 37.7, P 92 B/P 144/80 pain 3/10 sharp in abdomen. Urine output 200 mL clear amber. Distended abdomen, hypoactive bowel sounds, diminished and shallow lung sounds. No edema, cap refill

His afternoon assessment the same day includes R 30, T 38.4, O2 91%, B/P 150/86, no nausea or vomiting, urine output: 60 mL/hr., he is awake and oriented x3, rales and fluid sounds in lungs, pain 4/10 located in R&L chest and gets worse when deep breathing, pt states pain in chest is worse than his abdominal incision. His tissue perfusion/cap refill are fine. He has a productive cough with green sputum. Hypoactive bowel sounds. No edema.

It is clear to me that this patient has an infection. In the scenario our teacher says we have not concluded whether his infection is related to pneumonia or foley catheter and that we would need to have a urinalysis done to check for infection and a sputum sample be done to test for pneumonia. Without knowing what specifically is causing this infection how can i come up with a priority nursing diagnosis? It's quite clear pneumonia is more likely going on and the cause of this infection but nothing has been proven.

[beekee]

Stop focusing on the medical diagnosis. Which part of the assessment are most concerning to a nurse?

[Aliyune]

Beekee is right, doesn't matter at all what the medical diagnosis is. You have all the info you need in the assessment data to make a plan. 'Priority' is a BIG key word in nursing school. Visions of your Maslow's Hierarchy and, here's the big on here, your ABCs! Start there.

[nursej22, MSN, RN]

For ineffective gas exchange you would usually need abnormal blood gases.

[sirI, MSN, APRN, NP]

Duplicate threads merged.

[HiddenAngels]

Uhhh.. Further assess that chest pain.. Coughing only or?? Does sound like PNA though.. So go with Ineffective Airway Clearance.. Respirs are too high plus he's gpt rales.. I would give risk for infection a close second..