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Nursing Diagnosis

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Posted about 5 years ago

 

 Nurses:


I am trying to work on the prep for my case study paper and I am having trouble with my nursing diagnosis. My patient has RLQ abdominal pain, bloody stool, and has a pain of 7/10. 


The diagnosis I have so far is:


Acute abdominal pain r/t ______________ aeb patient stating pain level is "7 out of 10".  


I cannot figure out the r/t part- she "may" have ischemic bowel but I don't think she has actually been diagnosed with it. 


Any help is greatly appreciated!


 


Thanks!

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Rate This | Posted about 5 years ago

 

This was several years ago for me, but we could use the word possible in front of undiagnosed diagnoses.


so- acute abd pain r/t possible ischemic bowel aed..... I am not sure if that's kosher where you are but I hope this helps.


 

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Rate This | Posted about 5 years ago

 

 Or: you could just say undiagnosed medical condition. I had several instructors who would not allow a medical diagnosis anywhere in the nursing diagnoses statement. I HATE NURSING CARE PLANS. I hated writing them and I hated grading them.

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Rate This | Posted about 5 years ago

 

 Thanks for both of your help! I ended up using "unknown cause" but then when I got to clinical this morning it turned out that she had surgery two days ago to remove part of her bowel and the dr hadn't put the notes in the computer from the surgery. Luckily my instructor took pitty on me since the patient's bowel problems were the LEAST of her concerns. 


I don't completely understand the point of actually writing care plans since most care plans include clicking on several boxes in a computer.


Oh well, I just think of it as paying my dues to become an RN.


Thanks again!


 


 

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Rate This | Posted about 5 years ago

 

The point of the stupid things that no one uses anymore is to teach you the nursing process

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Rate This | Posted about 5 years ago

 

 CD-


I think I am "sort-of" learning the nursing process. The program that I am in focusses a lot on theory. All of the students keep moaning and groaning on how they wish we would have more clinical time (and we will- we have six more quarters with at least 1, sometimes 2, clinical courses each quarter). I have to do a case study paper utilizing the nursing process to analyze the care of my patient for this past week. The paper has to include rationale to manage abnormal labs as well as rationale from journal articles regarding interventions for my nursing diagnosis. I guess we'll have to see how the paper goes...