Surprise, another nursing diag question LOL

[RNKel, ASN, RN]

I'm doing "ok" with my nursing diagnosis, except I seem to stumble a bit on the "related to" part. I know it's the cause of the diagnosis. But I'm not sure exactly how to word it most of the time. We can't put the actual medical diagnosis there... but what if that is the cause? For example; my patient was a bilat TKR, I had him 2 days post op. I am using pain as one of my diagnoses. I have my 10 pieces of supporting data. I know my AEB. I'm stuck at my RT. I'm not sure if it is acceptable to say "Pain RT bilat TKR AEB grimacing, requesting pain med, diaphoresis". A lot of students just put "RT disease process". Obviously his pain is caused by the surgery. Any advice on how to get past my "RT roadblock"? LOL Thanks. :)

[Daytonite, BSN, RN]

Do you have a nursing diagnosis reference or a care plan book with NANDA reference in it? They list related factors. But for the fact that the doctor sliced him open and went in there and fooled around and put in a new knee, he wouldn't be in this pain.

Acute Pain R/T surgical intervention AEB grimacing, diaphoresis and verbal requests for pain medication.

[RNKel, ASN, RN]

Thanks Daytonite. Yes, I now have a book, but none of the related factors listed had anything to do w/ surgery, so I wasn't sure what I could put. Thanks for your help!

[Daytonite, BSN, RN]

See below.

[Daytonite, BSN, RN]

Well, you're allowed to tweak the related factors a little. The related factor for Acute Pain is "Injury agents (biological, chemical, physical, psychological)". Surgery would be a physical injury agent. You just need to tweak it to specifically say "surgical intervention" or something similar. "Trauma" works for someone who has a broken bone from an accident; "exposure to toxic fumes" for someone in a fire who breathed in smoke and toxic gasses; etc. The trick is staying away from using medical diseases. It's kind of a word game.