hi, ana3neurona, and welcome to allnurses!
you must follow certain rules when writing a care plan. you must assess the patient first and determine the abnormal responses, or symptoms, they are having. from that list of symptoms that you compile you are then able to determine nursing diagnoses, nursing interventions and outcomes.
from what you have already mentioned, your patient has these abnormal responses, or symptoms:
- abdominal pain
- pain when voiding
- difficulty urinating
if this is not a real patient you should also look up the signs and symptoms of acute pyelonephritis. if this was a real patient you still should look up this information because you need to know the pathophysiology of the disease anyway to help you determine the related factors for your nursing diagnostic statements. you also need to learn about how the doctors diagnose and treat the disease. in addition, you need to double check that you didn't miss any of the symptoms in the patient.
pain r/t irritation and inflammation of the urinary tract s/t pyelonephritis aeb difficulty voiding and complaining of pain
first of all, this is the incorrect label for the nursing diagnosis. it is actually acute pain
. here are links to web pages about it: [color=#3366ff]acute pain
second, "irritation" is not necessarily a cause of physical pain and, unless stated, you cannot assume the irritation is painful.
third, difficulty voiding, or dysuria, also doesn't cause pain, at least it does not state that in the assessment, so you can't assume it.
when you go to either of the above web sites for acute pain
, read the list of items under the heading of defining characteristics
. those are the symptoms for that nursing diagnosis. every nursing diagnosis has a set of signs and symptoms (just like every medical diagnosis). another descriptor of pain is rating it on a scale of 1 to 10.
better: acute pain r/t inflammation of urinary system aeb abdominal pain and pain when voiding.
difficulty urinating (dysuria) can be diagnosed as impaired urinary elimination.
here are links to web pages about it: [color=#3366ff]impaired urinary elimination
you need a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
- your instructors might have given it to you.
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
there are (1) nursing diagnosis books and (2) care plan books. each type focuses on different information. nursing diagnosis books often list the current nanda diagnoses alphabetically and give the nanda taxonomy information along with noc (outcomes) and nic (interventions) links. care plan books most often contain care plans for the most commonly occurring medical/surgical
diseases and conditions organized by body system. many care plan books also contain some of the nanda information for the nursing diagnoses they use, but the nursing diagnoses are spread throughout these books and not all the current 188 diagnoses are necessarily used. psych and ob care plans are often not included in these books.
please read the information of this sticky thread first. if you still have questions, then please ask