Help with care plan regarding abdominal pain

[tpw08002]

Hi! I am doing my first care plan (yikes) and am having trouble coming up with a proper nursing diagnosis. My patient has complained of left lower abdominal pain x 3 weeks. The pain level is a 5/10 and he grimaced upon palpation. I am doing my rotation at a prison, so this particular patient does not have easy access to CT scans, xrays, etc. The abdominal pain is of an unknown origin. He has had no trouble with BMs while having this pain and is passing flatus. I was thinking of something along the lines of "Acute pain r/t ________ AEB pain 5/10, elevated pulse, and grimacing upon palpation." Would it be appropriate to say "r/t abdominal pain of an unknown origin"? I appreciate any help!p.MsoNormal, li.MsoNormal, div.MsoNormal { margin: 0in 0in 0.0001pt; font-size: 12pt; font-family: "Times New Roman"; }div.Section1 { page: Section1; }

[Double-Helix, BSN, RN]

Yes, it would be appropriate. Your diagnosis should actually read: Acute pain, abdominal r/t origin unknown AEB....

[Esme12, ASN, BSN, RN]

care plan basics:

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

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

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:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems

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

i can't take credit for the above rnwriter and daytonite were the brainiacs.....

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx