Question

The nurse receives a 12-year-old girl from the operating room after an emergent appendectomy due to ruptured appendix. Upon arrival to the postanesthesia care unit, the patient is drowsy, but arousable to voice; she was extubated in the operating room and is receiving oxygen by facemask at 40%. she has two peripheral IVs in her left arm that are infusing lactated Ringers solution at 100mL/hr. A nasogatric tube is attached to low constant suction, and a small amount of aspirate is noted.She has a urinary catheter that is draining clear, yellow urine. Her abdominal dressing is dry and intact. Upon arousal, she complains of abdominal pain.(Learning objective 5).
a. What NANDA- approved nursing diagnosis may be relevant to this patient?
b. Once the nursing diagnoses are determined, what steps does the nurse take to complete the planning phase of the Nursing process?
c. What is the difference between nursing diagnoses and collaborative problems?

Answer 1

a. Nursing Diagnosis

1. Acute pain related to the presence of surgical incision as evidenced by reports of pain and facial grimacing

2. The risk for Deficient Fluid Volume related to postoperative restrictions (NPO), Inflammation of peritoneum with sequestration of fluid

3. The risk for infection related to inadequate primary defences like rupture of the appendix, surgical incision, invasive procedures

4. Deficient Knowledge related lack of exposure or information misinterpretation evidenced by questions and verbalization of problem/concerns

b. After the patient and nurse agree on nursing diagnosis the plan of action can be developed based on the outcome criteria.

Steps for the plan of action

• Prioritize the nursing diagnosis
• Determine the outcome criteria
• Determine the short term and long term goals based on measurable evidence.
• Problem-oriented assessment
• Data validation and interpretation
• Plan of actions to achieve outcome

c. Nursing diagnosis along with the collaborative problems (potential problems) denotes the range of patient conditions that require nursing care.

Nursing diagnosis is the second step of the nursing process which classifies health problems within the domain of nursing. It can be a nurse’s clinical judgment about individual, family, or community reactions to actual and potential health-related problems or life processes that the nurse is licensed and competent to treat. When possible the patient is involved in the nursing diagnosis process.

A collaborative problem is an actual or potential physiological complication that can affect the patient’s status and the onset of changes is determined by the nurses. For the management of the collaborative problems, the nurses work in collaboration with the personnel from other health care disciplines. For example, the nurses manage collaborative problem such as paralysis using the help from medical, nursing, and allied health (e.g., physical therapy) interventions.