Stumped on Nursing Diagnosis for Episiotomy

Marie_LPN, RN, LPN, RN · Nov 25, 2004

A pt. may make a face when they are in pain, but, how would you explain that on a careplan, without using opinion?

mavnurse · Nov 25, 2004

Just change it all together and use the cop-out diagnosis we do in my group when we can't think of anything else: Risk for Falls.

I think there were some people who used that every week.

FuturenurseCA&O · Nov 25, 2004

A pt. may make a face when they are in pain, but, how would you explain that on a careplan, without using opinion?

AEB: frequent grimacing, moaning.

You could also note vital signs if higher than normal limits.

~Futurenurse

Marie_LPN, RN, LPN, RN · Nov 25, 2004

AEB: frequent grimacing, moaning.
You could also note vital signs if higher than normal limits.
~Futurenurse

Bruising, edema and edge approximation are things you can see. You cannot see actual pain, you can just see the person's reaction to it and ask them about it.

Quoted from Saunders "Introduction to Medical-Surgical Nursing" 3rd Ed., Chapter 11, pg. 115:

Subjective data consists of information that is reported by the patient and family memebers in a helth history in response to direct questioning or in spontaneous statements...is usually documented in the pt.'s own words...only the pt. can describe.

Objective data are those that the nurse or other members of the health care team observe through observation, physical exam or diagnostic testing. OD can be seen or measured. (Example: lab, values, HR, wound condition)

pg 116 under "Objective Data": Examples: At. pt.'s noisy loud breathing can indicate respiratory difficulty. Cold clammy skin may signal shock.

The bruising and edema can be visualized. Pain, itself, cannot actually be seen, the reaction to it may be seen. But someone can grimace and not be in pain, so that's not necessarily evidence of pain, unless the pt informs you of pain.

Nikki730 · Nov 25, 2004

Just my opinion, but I think there's a pretty strong correlation between facial expression and evidence of pain. For example, everyone's probably seen that card that you can show to a person who can not speak, or speaks a different language and there's no interpretor handy (the one with the faces with different expressions on it). It lets the client pick the face that corresponds to how he/she is feeling. I have a nursing care plan book that lists "Facial mask of pain" and "distraction" under the category of "possibly evidenced by" for it's Nursing diagnoses of "Acute Pain." The person may of course deny that their facial expression is related to pain, (maybe they were just remembering something unpleasant) or that their demeanor is "distracted", and you could let it go at that.

Of course, it's true that you can not see pain, just reactions that could be indicative of pain. So you would at least try to follow up those clues with questioning the patient about possible pain.

The original poster probably knows her instructor's likes & dislikes regarding how a careplan should read. So she can take what's useful to her and leave the rest.

Just my 2 cents.