NANDA for acute pain?

Esme12, ASN, BSN, RN · Oct 24, 2012

I have a case study in which I must come up with 2 complete NANDAs.
Pt admitted from ER is 87yo female with three day hx of intermitten abdominal pain, bloating, nausea, and vomiting. Pt does not speak english and her grandson is at the bedside. She just moved in with him after living in Mexico. She moved to the US after the death of her husband 6mos ago. PMH include colectomy for colon cancer 6years ago, ventral hernia repair 2 years ago. Pt does not have hx of CAD, DM, or pulmonary disease. Home medication include ibuprofen PRN. Aleergies is Sulfa and mepridine.. Tentative dx is small bowel obstruction secondary to adhesions. She is admitted for dx work up.
So the NANDAs I came up with is:
Dysfunctional gastrointestinal motility R/T the blockage of stool in the intestines AEB andominal pain, bloating, nausea, and vomiting.
Acute pain R/T blockage of stool in intestines AEB intermitten abdominal pain for 3 days.
I like my first NANDA, I don't like my second one! I feel like I Should look for something besides the bowel obstruction. Right? Or is it okay to have two nandas for the same thing?
Also, my R/T...can I just put R/T small bowel obstruction or does it have to be the definition. I know you cannot use a medical dx in the R/T which is why I put the deifnition of small bowel obstruction...but is this really a med dx?
Any suggestions?

OK...first...... Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition (nanda list as contributed by vickirn (assistant administrator)

nursing diagnoses 2012 - 2014.pdf‎

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

So look at your scenario.......

Pt admitted from ER is 87yo female with three day hx of intermittent abdominal pain, bloating, nausea, and vomiting. Pt does not speak English and her grandson is at the bedside. She just moved in with him after living in Mexico. She moved to the US after the death of her husband 6mos ago. PMH include colectomy for colon cancer 6years ago, ventral hernia repair 2 years ago. Pt does not have hx of CAD, DM, or pulmonary disease. Home medication include ibuprofen PRN. Allergies is Sulfa and Meperidine. Tentative dx is small bowel obstruction secondary to adhesion's. She is admitted for dx work up.

You know from your scenario that your patient has intermittent abdominal pain, bloating, nausea, and vomiting with a tenative diagnosis of..... small bowel obstruction secondary to adhesion's. Your nursing diagnosis.........Dysfunctional gastrointestinal motility R/T the blockage of stool in the intestines AEB abdominal pain, bloating, nausea, and vomiting.

Is the blockage due to stool????

What is your patients main concern that brought her to the hospital? Pain right?

So we now know that Your patients primary problem is acute pain related to the dysfunctional gastric motility that may be caused by the SBO (small bowel obstruction) and you know this because the patient complains of intermittent abdominal pain, bloating, nausea, and vomiting.....

What does NANDA say about acute pain?

Your patients other symptom/problem is the complaint of nausea/vomiting.......what does NANDA say about nausea?

Can the nausea/vomiting cause Imbalanced Nutrition: more than body requirements?

Your patient has a language barrier...how will this affect this patient and her care? Can a language barrier affect the patient enough to cause her deficirnt knoledge about her plan of care?

Do you see where I am going with this????

tammy_zeidan09 · Oct 24, 2012

The primary reason that bought her to the ER was pain. So that is my MAIN focus. I should add that she had no VS taken and her Labs were pending..but she was ordered to be on 100ml/h of NS with KCL. She is also on 3 L of O2 via NC.

Butttttt...there is no "signs or symptoms" of respitory distress. To fit a Dx to my patient, I need signs and symptoms..but she doesn't have s/s of resp distress, crackles, wheezing, ronchi, respitory rate..so I cannot use that since I have no R/T or AEB's. right?

I thought of Imbalanced nutrition: less than body requirements bc she is NPO (did I forget to say that?) and currently not consuming anything..though she is on IV fluids, she is not taking in many calories and she is NPO..But CURRENTLY she is not showing signs and symptoms of imbalnaced nutrition besides abdominal pain, but that is due to a bowel obstruction..not food [maybe?]

So as of now, it seemsas though pt main concern is PAIN.

Acute pain RT blockage of stool in intrestines AEB intermitten abdominal pain for three days. That is the FIRST THING we should look at to help do something for the pt like administer PRN pain meds, reposition, etc.

Now the second thing we should worry about is her Imbalanced nutrition..clearly she is not getting adequate calories!I was looking for a "risk for" less than, but couldn't find one in two of my Dx books.

I am a little confused, you said imbalanced nutrition:"more than" rt vomiting? Howso? wouldn't that decrease?

I was thinking about the language barrier, but like you said I need signs and symptoms to drive my dx. How did her deficiency in knowldge cause a SBO or pain?

It is not indicated that she is unfamiliar with her self care. Does that make sense?

For instance: Knowledge deficient R/T....what? AEB not being able to speak english...what can she possibly be knowledge deficient in if nothing has been said to her or true dx have been made..

I know I am so scattered...sorry! I def don't mind te criticsm. My instructor is big on acuity..so I enjoy that challenge!

tammy_zeidan09 · Oct 24, 2012

Also, to provide two interventions to promote comfort for the above scenerio...Let me know if you think I should be more specific..

Raise HOB to ease the feeling of nausea and prevent aspiration if vomiting.

It is also indicated the pt is on 3L of O2 via NC. I would wrap the canula with gauze or cotton around the ear to prevent pressure sores or irritation.

I have thought of attaching NC to a humidifier, but if she is on 3L, chances are it isn't too drying to the nares. And perhaps the gauze is more important, right?

Should I look at something more acute?

Esme12, ASN, BSN, RN · Oct 24, 2012

The primary reason that bought her to the ER was pain. So that is my MAIN focus. I should add that she had no VS taken and her Labs were pending..but she was ordered to be on 100ml/h of NS with KCL. She is also on 3 L of O2 via NC.
Butttttt...there is no "signs or symptoms" of respiratory distress. To fit a Dx to my patient, I need signs and symptoms..but she doesn't have s/s of resp distress, crackles, wheezing, ronchi, respiratory rate..so I cannot use that since I have no R/T or AEB's. right?
I thought of Imbalanced nutrition: less than body requirements bc she is NPO (did I forget to say that?) and currently not consuming anything..though she is on IV fluids, she is not taking in many calories and she is NPO..But CURRENTLY she is not showing signs and symptoms of imbalanced nutrition besides abdominal pain, but that is due to a bowel obstruction..not food [maybe?]
So as of now, it seems as though pt main concern is PAIN.
Acute pain RT blockage of stool in intestines AEB intermittent abdominal pain for three days. That is the FIRST THING we should look at to help do something for the pt like administer PRN pain meds, reposition, etc.
Now the second thing we should worry about is her Imbalanced nutrition..clearly she is not getting adequate calories!I was looking for a "risk for" less than, but couldn't find one in two of my Dx books.
I am a little confused, you said imbalanced nutrition:"more than" rt vomiting? How so? wouldn't that decrease?
I was thinking about the language barrier, but like you said I need signs and symptoms to drive my dx. How did her deficiency in knowledge cause a SBO or pain?
It is not indicated that she is unfamiliar with her self care. Does that make sense?
For instance: Knowledge deficient R/T....what? AEB not being able to speak English...what can she possibly be knowledge deficient in if nothing has been said to her or true dx have been made..
I know I am so scattered...sorry! I def don't mind the criticism. My instructor is big on acuity..so I enjoy that challenge!

Sorry about the more than....... :shy: of course I meant less than...... :facepalm: I'm going to blame that on temporary insanity. :confused:

Straight up....about the oxygen.....you go to the emergency and you are old...you get oxygen. It's a billable charge. AND.....she may have been hyperventilating because of the pain when she arrived.....but mostly because she is old and went to the ED...is why she got O2.....and you never know if abdominal pain, nausea, vomiting is actually cardiac in nature or is they have an abdominal aneurysm about to rupture....so they get O2.

I am not criticizing you Tammy....I am just trying to teach you how to think like a nurse. What should concern you the most....what should you address first......this is probably the hardest thing to learn. Of course your CI is big on acuity....for we should all care about what affects the patient the most and place that at the top.

If I were writing in pain...all I want is something for pain....I could care less if my last tetnus shot was 5 years ago.

Let go of all of your previous thoughts......LOOK at the patient. What do you SEE? Is this a real patient? Did you actually assess them? If this was your MOM what would you want the nurses to know and be concerned about.

So correct...your new concern is pain. But I repeat.....how do you know it is from stool. The scenario tells you they think it is from adhesions. So.....what, are adhesions? Are adhesions in this patient caused by stool? or are they caused by scar tissue from her previous surgeries like her colectomy for cancer? What is a colectomy?

OK...so imbalanced nutrition....LESS THAN ...body requirements. What makes you say at risk for when it is clear she is vomiting and not receiving the nutrients necessary. What does NANDA say about Imbalanced Nutrition: less than body requirements what are the defining characteristics (as evidenced by) and related factors (related to)....your patient is a text book picture.

She is however at "risk for deficient knowledge" due to language barrier. If she can't understand you......... how do you teach her about what is going on, what is the plan, what meds you are giving, consenting to any procedures. We would need to know what to look for but there would be no defining characteristics because we are just looking for this as a potential problem in the near future....from what you have told me we do not know that as of yet.

Do you see it now? I was under the understanding that you can add to/remove the at risk to the NANDA diagnosis. what does you CI say?

Esme12, ASN, BSN, RN · Oct 24, 2012

Also, to provide two interventions to promote comfort for the above scenario...Let me know if you think I should be more specific..
Raise HOB to ease the feeling of nausea and prevent aspiration if vomiting.
It is also indicated the pt is on 3L of O2 via NC. I would wrap the cannula with gauze or cotton around the ear to prevent pressure sores or irritation.
I have thought of attaching NC to a humidifier, but if she is on 3L, chances are it isn't too drying to the nares. And perhaps the gauze is more important, right?
Should I look at something more acute?

With Your patients primary problem is acute pain related to the dysfunctional gastric motility that may be caused by the SBO (small bowel obstruction) and you know this because(as evidenced by)the patient complaints of intermittent abdominal pain, bloating, nausea, and vomiting.....

What promotes comfort to you if you are in pain? Position for comfort? A nice quiet room? Some pain medicine? What evidence do you have that the O2 is bothering her? Is she taking it off, restless and pulling it out of her nose?

When you are nauseated and vomiting....what makes you feel better? Swishing out your mouth? (oral care) A cool cloth?

You can also consider analgesics and anti-emetics.

tammy_zeidan09 · Oct 24, 2012

Wow you're awesome. So helpful thank you very much.

You're right I can promote comfort by repositioning pt or administer analgesic. She didn't show signs of discomfort for NC I just assumed which I guess I shouldn't.

Imbalanced nutrition less than has characteristics of inability to ingest food. That would be one since she is NPO. Also abdominal pain, though like you said it can be from many things. So pain and nutrition are the more important for pt correct?

And then perhaps dysfunction mobility and deficient knowledge risk for.

Buttt I have one more question, wouldn't dysfunctional gastric motility be of concern before imbalance nutrition. Bc say we address her nutrition and give her a feeding tube, the SBO will still be there. I mean she can be put on TPN but shouldnt we first try to address the motility before something invasive.

Esme12, ASN, BSN, RN · Oct 24, 2012

Yes but.....pain is your priority. While she has pain nothing else matters.....so to speak.

You really like the dysfunctional gastric mobility don't you.....LOL.

If you have to use it.........Use it this way.....

Acute pain R/T dysfunctional gastric mobility caused by adhesions in the small bowel causing obstruction AEB intermittent abdominal pain, bloating, nausea, and vomiting.

Ok we used it.

Then imbalance nutrition less than AEB vomiting (unable to ingest nutrients) abd pain, bloating adn the inability to process/digest food AEB the SBO (small bowel obstruction)

Then your at risk communication/knowledge. If she can't understand you you can't teach HER.

I don't like writing the diagnosis as 1) you need to be thinking this stuff up yourself....and 2) every nursing instructor has their own personal variations that they prefer.

I hope this helps.

nurseprnRN, BSN, RN · Oct 24, 2012

Have you looked at the actual NANDA-I 2012-2014 (current edition) book? If you don't have it, you're working under a handicap. Why? Because I can see a whole lot of useful potential nursing diagnoses in there (DEPENDING ON YOUR ASSESSMENT) that give you defining characteristics, which you can then see (or not see) in your assessment.

Amazon, free 2-day shipping, every student should have it even if the faculty forgot to put it on the bookstore list. Trust me on this one-- you'll never have a hard time justifying your nursing plan of care to your faculty again.

tammy_zeidan09 · Oct 25, 2012

Thank you!! I appreicate your help. I know what you mean about not giving dx. You definitly shouldn't..your questions really challenged me and helped me think!

Today in class when we had more case studies I asked my group what is the PRIMARY nanda. lol

I just want to be thinkin on the same path as a nurse!

GrnTea, nooooo I don't believe I do have that edition. I believe mine is '09!

Esme12, ASN, BSN, RN · Oct 25, 2012

Tammy you need a current book. They change the diagnosis......I have a list here (as I had earlier in the post) the VickyRN gave....

nursing diagnoses 2012 - 2014.pdf‎

It is one of the challenges of nursing school.....thinking like a nurse. ON to the next...