Interactive Activity: With a partner, do the following: (1) select the one nursing diagnosis that is of priority at this time, (2) provide a rationale for your selection, and (3) list three nursing interventions that assist to meet the needs of the patient:
All of the following Nursing Diagnoses may apply to Mrs. Potts.
Risk for infection, Risk for impaired skin integrity, Pain, Anxiety, Ineffective airway clearance, Fatigue, Impaired physical mobility, Altered nutrition: Less than body requirements, Body image disturbance, Risk for fluid volume deficit, Fear.
Nursing Diagnosis | Rationale | Nursing Interventions
On the morning of the third postop day, the N/G tube was removed per physician order and Mrs. Potts was started on a clear liquid diet. In the afternoon the assessment findings included:
Stoma edematous and pale, abdomen distended, c/o of pain.
Instructions: Based on the third postop day assessment, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing interventions listed and identify your action plan for the follow-up care of Mrs. Potts.
NURSING INTERVENTIONS
A. Take the vital signs
B. Prepare to insert N/G tube
C. Assess colostomy bag and stoma
D. Notify physician stat
E. Place on NPO
F. Check IV patency
DECISION-MAKING DIAGRAM
Prepare Mrs. Potts for surgery
New Action Plan
Signs and symptoms of stomal ischemia
Priority Problem
NOTES