Ok y'all once again I am a dummy and I just don't get this stuff. Nursing diagnoses are going to be the death of me!
So I have a patient who had elective surgery and after surgery was admitted because they experienced severe post-op nausea and chest pain (the surgery was not cardiac or gastrointestinal in nature but the patient does have a history of cardiac and gastrointestinal conditions.) I needed to come up with a nursing diagnosis and care plan for this patient and I needed a nursing research based article that recommended nursing interventions for my patient and for one reason or another my patient was excluded from most of the articles I found. I did manage to find an article on managing postoperative pain and it has recommended interventions (and pending my instructors approval it should be ok) but my issue now is coming up with the right nursing diagnosis. I believe that because this pain is not chronic but occurred postoperative that the appropriate nursing diagnosis is "Acute Pain" but I'm not sure how I should finish the rest of the diagnosis, I know that the "related to" portion and "as evidence by" is also required. I have read that tissue damage or tissue disruption due to surgery is the "related to" in "Acute Pain" diagnoses but since the pain was not at the surgical site I am not sure how to direct the diagnosis to the chest pain experienced. As far as the "as evidence by" portion goes I am not sure how I would phrase this; on the day that I had the patient he had received pain medication from the night nurse about an hour before I came in so when I assessed his pain it was decreased to a 2 out of 10 but he described that it was a feeling of throbbing and tightness located in the left side of his chest (I did report the pain to the nurse for the patient and the physician and I documented the pain.) Should I put that he said his pain was a 2/10 or should I just say that the patient reported pain? I looked in the records and when the patient was brought to the PACU following the patient had severe chest pain and nausea but it did not give a rating for the pain and over the next few days the patient was in the hospital the patient had bouts with severe chest pain and continued nausea. I ask about whether I should include the pain rating of 2/10 in the nursing diagnosis because at the hospital I am at it is policy not to medicate for pain if it is rated as less than a 4/10 so would the "Acute Pain" still be a relevant diagnosis? I know that there are many other nursing diagnoses that I could come up with for this patient but I couldn't find relevant articles to correlate with the care plan. Thank you for your help ahead of time.