Help with care plan!

[cjennings15]

I need help with nursing diagnosis for this pt. Our primary problems shouldnt be pain/psychological but I cant think of anything!!

Over the summer, she presented in the ER suffering from worsening, persistent RUQ abdominal pain. CT scan showed a right posterior hepatic lesion ~5-6 cms and suggestive of hemorrhage into a hepatic adenoma. She also complained of constipation/rectal bleeding and a barium enema was performed with normal results. On August 9th, she had the hepatic adenoma removed from her liver and it ended up being benign. Her gallbladder was also removed during the surgery due to the proximity of the surgery despite the absence of gallstones.On October 1st, she returned to the ER due to painful post op symptoms. CT scan showed subhepatic fluid and it was then drained by interventional radiology. Initial drainage was 35 mL purulent fluid and a JP drain was put in place. Cultures on drainage came back negative and determined to be sterile. Drainage is now minimal and symptoms in that area have improved but she is still having RUQ pain that is made worse by activity, eating, and bearing down. Due to her nausea with eating, they performed an esophagogastroduodenoscopy on October 5th that came back normal. When standing, there was slight epigastric shadowing in the RUQ just below her incision line from the hepatic adenoma removal. There was a marked circular area about 2.5 inches in diameter that was firm and very tender. She stated that it doesn't feel like her skin when she touches it. The day I was there, October 6th, she had an ultrasound to see if removal of the JP drain was indicated or if there was any more fluid. They found a 4x5x4 cm collection of fluid adjacent to the posterior hepatic lobe and left the drain in place.