Help needed with care plan for PT with renal cystic mass...

[amandapg]

Hello there!

I had a patient at clinicals that I thought was a little hard to do the care plan for. Here is a little about the patient:

Pt is a 43/female admitted because of right flank pain (which has been going on for 3 months) on a VAS scale of 7/10. CT scan showed a 16.4 cm cystic mass on the right kidney, pressing on the inferior margin of the liver. A needle biopsy revealed the mass was benign. Pt has a history of controlled hypertension, and family history is positive for diabetes, hypertension, and hypercholesterolemia. Pt also reported she is trying to get pregnant.

The nursing diagnoses I chose are:

1. Acute pain r/t 16.4 cm cystic mass on right kidney a/e/b patient reporting right flank pain rated 7/10 on a VAS scale.

2. Imbalanced nutrition: less than the body requirements r/t food intake less than the RDA a/e/b patient eating less than 50% of all meals.

3. Readiness for Advanced Self-Health Management r/t expresses desires to manage illness a/e/b keeping hypertension controlled.

I am mostly worried about the last two, not really sure if they are a priority diagnosis or if they should even be a diagnosis for this patient at all. I wanted one that would cover the right flank pain, and another that would cover her risk for developing diabetes (and the fact that she has hypertension) because this patient IS obese. I just don't think number 2 and 3 fit.

Any help would be appreciated! Thank you. :)

[amandapg]

Oh and one last thing... my teacher would prefer us not using "RISK FOR" nursing diagnoses...

[EricJRN, MSN, RN]

You've done a great job of thinking about the patient's complaint, history and diagnostic test results. Did you get a chance to perform a physical assessment? That's really where a lot of your nursing diagnosis information is going to be.