GI question

[sleepy1010]

Hi,

I am doing a care plan on a pt who came to the hospital after having 1 month of RLQ pain when it statrted to radiate to the LLQ and L chest. He had a chest xray and EKG which were normal and the next day, the day he was my pt, he had a colonoscopy scheduled. On his Kardex the admitting diagnosis said "colon mass" rather than abdominal pain. My question is how did they know this before they did the colonoscopy? And also since his cheif complaint was pain would that be my top priority as a nursing diagnosis? His ALK was high, and RBC, Hg, HCT were all low. Those were the only abnormal labs. Vital were within normal limits for the patient....

[sleepy1010]

Oh and hypertension and GerD were his only past medical issues

[Daytonite, BSN, RN]

on his kardex the admitting diagnosis said "colon mass" rather than abdominal pain. my question is how did they know this before they did the colonoscopy?

they found this information somewhere in the chart. did you look in the physician's progress notes or history and physical? the mass could have been discovered by the physician when he did his physical examination.

and also since his cheif complaint was pain would that be my top priority as a nursing diagnosis?

no, the chief medical complaint is not the same as a nursing diagnosis. the chief medical complaint is something the

doctor

states is wrong with the patient. a

nursing diagnosis

is arrived at by the

nurse

after having done an assessment of the patient. for more direction on how to construct a care plan, see this sticky thread and examples:

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

-

help with care plans

before you can begin to start a care plan for this patient you need to assemble your assessment data on this patient. assessment consists of:

• a health history (review of systems)
  
  
• 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 they are taking