I'm a second semester nursing student and have a patient for this week who presented to the ER with abdominal pain (8 on a 1-10 scale). I need to come up with her top 5 priority nursing diagnosis, or as my CI likes to say "I want to see the top 5 things that'll kill your patient". They were still running tests to figure out what is wrong with her when I was there for data collection this afternoon. She has a hx of pancreatitis (pt thinks this is her problem now), superior mesentaric artery syndrome, and gastrojejunostomy. I've got Acute Pain r/t epigastric pain -- I know my r/t probably won't work, don't think you can double on pain, but I'll work on that -- can anyone help me with a direction to go for the next 4? WBC is high, Hgb and Hct are low, K is low (she's getting it in her IV), ALT and AST are high, and her UA was within ormal limits. Thanks!!!
Feb 15, '10
let me put it this way. . .if you take your car to a mechanic he also diagnoses a problem. how do you think he does that? he doesn't pull diagnoses out of the air. he, or she, listens to what you have to say (subjective data) and then they do an assessment (objective data). from that data they extract what is abnormal. what is abnormal are symptoms of the problem. doctors did the same to diagnose that superior mesenteric artery syndrome that your patient has. we nurses do exactly the same thing to diagnose the patient's nursing problems. the fact that maybe the patient wasn't present may be a bit of a problem for you, but there was always the chart to look at, or i would have tracked down the chart at whatever lab the patient had been taken to in order to see the chart. i really can't tell you anything about what other nursing diagnoses this patient might have because you have supplied no other data. nursing assessment
- a health history (review of systems) [font=arial unicode ms]
- performing a physical exam
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
and then listing about what is abnormal. what is abnormal becomes the symptoms of their nursing problems to which you will attach names, or nursing diagnoses to.
Feb 16, '10
Unfortunately, I'm sure like my teachers do, you need to make nursing diagnoses before you even get to interact with your patient.
If we look at the low HGB/HCT- risk for fluid volume excess- potentially related to abd pain (this is guesswork since I don't know her actual dx). Risk for activity intolerance- r/t the pain and potential orthostatic hypotension. Risk for altered breathing pattern- less O2 being delivered to tissues.
I'm not an expert just another student like you but these are some educated guesses