Healp with Nursing Dx

[Geethaanchaly]

Hello,

I am a nursing student and could you please help me with finding a best nursing diagnosis for the following case scenario, Thank you.

Mr. D, a 62 year old male, was admitted to your rehabilitation unit four days ago following a left hip replacement. He has a history of arthritis and had his right hip replaced 5 years ago. He is allergic to acetaminophen. On assessment, he is holding on to his left hip and winces with movement. He states he is having a pain rated 6/10 but does not want to be a bother and make a big deal about it. I'm OK.” He asks the nurse not to tell his family about his condition since his wife is going through treatment for cancer and he doesn't want her to worry about him”. He says that he can't wait to get home so he can be there for her”. He has been attending physiotherapy but the therapist says he has not been fully participating in his range of motion exercises and his discharge is going to be delayed. He is scheduled for his daily physiotherapy one hour from now. The change of shift report states that he was restless throughout the night but refused prn analgesia. His incision line is dry, intact and slightly red along the edges. Vital signs this morning are BP 160/90, HR 102, RR 24 T 37.2°C.

Doctor's orders are as follows:

Acetylsalicylic acid 650 mg po TID

Oxycodone 5 mg po q4-6h prn

[mindofmidwifery, ADN]

Do you have any suggestions or ideas in your head as to what his nursing diagnoses would be? What are your thoughts?

[AngelKissed857, BSN, RN]

Give us your ideas and we can help. But can't/won't do it for you.

[Geethaanchaly]

I am confused between "Stress, Overload" and Acute pain. I don't know which one I chose.

[mindofmidwifery, ADN]

I am confused between "Stress, Overload" and Acute pain. I don't know which one I chose.

You would choose stress overload for when the patient has known stressors that results in physical and/or psychological distress. Acute pain is a sudden or slow onset of pain with a predictable end and duration of less than 6 months. It doesn't sound like he is quite at stress overload and it would be your call whether or not he is experiencing acute pain. I would touch more along the lines of "caregiver role strain" as a nursing diagnosis for this patient since he is putting his role as a caregiver to his wife before his health needs.