Help with NCP

[Jitssy]

Hi,

I'm doing a nursing care plan for a client who experienced complications/side effects with using a PCA pump (mostly felt drowsy, later nausea and vomiting). I don't know which nursing diagnosis would be best for this client. I thought there was one for ineffective pain management, but there is none. What should be my diagnosis? I tried looking for other nursing diagnoses but none seem appropriate to what I want to talk about. Or should I just use the nursing diagnosis of Acute pain since her pain is originally from having multiple bone fractures.

[RN403, BSN, RN]

Your nursing diagnoses come from your assessment of your patient. After your assessment or from the assessment information given if this is not an actual patient; what issues did you identify?

For example: did this patient state that they were nauseous?

If yes, then one of you diagnoses would be "Nausea r/t xyz"

Did this patient state that they are in pain?

Then it would be "Acute pain r/t xyz AEB xyz"

Remember: Your NANDA nursing diagnoses come from YOUR assessment findings. You basically are outlining what you found to be abnormal.

[JustBeachyNurse, LPN]

You cannot take one aspect of your patient's presentation and push it into a nursing diagnosis. Nursing care plans start with ADPIE (assessment, diagnosis, plan, interventions, evaluation). So tell us about your patient? Pain level? Vital signs? Activity level? How long ago were the fractures? Traumatic onset or pathological fractures?

We cannot guide you without further information.

Do you have a copy of the NANDA-I 2012-2014 nursing diagnosis book? Do you have a nursing care plan book?

You must utilize the related factors and defining characteristics listed by NANDA-I for any actual nursing diagnosis and risk factors for risk for nursing diagnosis. You cannot add your own, you may need to specify based upon the criteria listed (such as AEB pulse ox less than 86% on room air)