[Medsport]

I'm working on my first care plan for my med-surg rotation. My patient had osteoarthritis and had a knee replaced. She also has some minor to moderate contractures of an elbow and wrist. She complained of pain twice during my shift, once when waking up and once after walking with OT (5 on a 1-10 scale). She was pre-medicated with several pain meds. Should I use acute or chronic pain as my no. 1 nursing diagnosis? I need 7 altogether and have these so far: 1. acute or chronic pain, 2. impaired skin integrity, 3. impaired physical mobility, 4. activity intolerance, 5. imbalanced nutrition: more than body req., 6. knowledge deficit: post-op care, 7. risk for infection, or 8. risk for injury. Are these in a pretty logical order, any I missed? The patient is about 60 pounds overweight, middle age, wears glasses, no other illness, has had C/S and hyster.

[adidasgirl0699]

This would be considered acute pain. You have a good list, and I would for sure use "risk for infection" and "risk for injury," as safety will be a big concern for this pt.

One thing I never quite figured out though... I was taught by most professors in nursing school that the "risk for" diagnoses belonged toward the bottom of the prioritized list b/c they were only risks. But I remember taking the HESI, and other NCLEX style questions and seeing prioritization questions. The answer for top priority was often "risk for injury." (And I see how in some situations, this would be extremely important.)

But still... Confusing

[BBFRN]

When doing your pain scale on the patient, ask if the pain is continuous or intermittent. Ask how long the pain has been going on. This will help you to determine if it's chronic or acute.

[Daytonite]

Hi, Medsport! Your determination as to whether to use Acute or Chronic Pain is based on what you found in your assessment of the patient. If the location and other factors of her pain are the same as the kind of pain she has typically had in the past prior to the surgery and what she has been medicating herself for in the past, then I would use Chronic Pain. However, if her pain is surgical pain and due to the surgery, then it should be addressed as Acute Pain. Again, I cannot stress enough that any decisions you make when choosing a nursing diagnosis ALWAYS rest on the data you obtained during the assessment of the patient.

As you know, I prioritize by Maslow and I have also disagreed with your instructors insistence on putting any diagnosis related to pain as the primary diagnosis. With a knee replacement, this patient's primary goal is going to be to be up and moving with her new joint. Nonetheless, this is that way I would prioritize your list of nursing diagnoses:

1. activity intolerance (physiological need for oxygen)
2. impaired skin integrity (physiological need for oxygen and nutrition)
3. imbalanced nutrition: more than body requirements (physiological need for nutrition)
4. impaired physical mobility (physiological need for movement)
5. acute pain (physiological need for comfort)
6. knowledge deficit: post-op care (self-actualization need for facts)
7. risk for infection (anticipatory safety need for protection)
8. risk for injury (anticipatory safety need for protection)

[Medsport]

Thanks, daytonite. I believe our instructors always want to put pain first if it applies for some reason. But for the rest, they look pretty good except my NDB says knowledge deficit does not necessarily describe a health state and nurses should include teaching as one of the interventions for all other diagnoses they make. Not sure if I agree with that. Also, you sound like you have the same opinion as my gf for the activity intolerance. I think impaired physical ability should be before act. int., but you guys don't. My book says not to use this label unless it is possible to increase the patients endurance and use it only if the patient reports fatigue or weakness in response to activity. I'm not sure what I would use for the R/T except maybe bed rest and immobility and the AEB? So, I don't know, maybe I'm making this harder than it is. It seems to take me forever (several hours) to figure out the dx, when some of my classmates can get it done in like 15 minutes...

[iceyspots]

chronic pain last 6 months or more
!

[morte]

you can have both, chronic and acute pain, at the same time.....the chronic may be part of the limiting factor in mobility....and may play a part in the obesity.....good luck