HELP Nursing Dx for diarrhea/abdominal pain

Daytonite, BSN, RN · Nov 18, 2009

it is irrelevant that the doctor has not determined a medical diagnosis. i know that you probably have a section on the care plan form you need to turn in that asks for this information. you need to put down what the doctor said the admission diagnosis was which can also be a symptom. in this case it will be "abdominal pain and diarrhea". doctors are allowed to do that and then spend the patient's time in the hospital investigating the cause of those symptoms. in his discharge summary which you will probably never see he will chart that her final diagnosis is a hiatus hernia so the hospital billers will be able to get paid the correct amount from the patient's insurance company. so, her medical diagnosis will eventually get changed--you just won't see it.

for care planning, however, this is good information to know, but we are interested in the patient's response to all that is happening to her. nursing care plans are all about determining what the patient's nursing problems are and doing something about them. the nursing process is the tool we use to problem solve and a care plan is nothing but one big list of problems and potential solutions. if you follow the steps of the nursing process to help you organize (critical think), the care plan will come together nicely and rationally. watch.

step #1 assessment. a good nursing assessment consists of:

doing a health history (review of systems) - the information you provided is that this 75-year old, obese patient came into the hospital with abdominal pain and diarrhea. she has a history of gi reflux, recent pneumonia, htn, osteoarthritis, allergic rhinitis, lumbar disc disorder, headache and facial pain, has had a hysterectomy in the past and stated she had some kind of tumors many years ago.
performing a physical exam - actually the only assessment data by you that i found in your post was this: "hopefully, there's nothing wrong with me." for a patient who has abdominal pain i would expect to see that you had assessed her abdomen and pain and you have included none of this information. how many stools was she having the day you had her and what was their consistency? there is specific assessment information that can be found when someone has abdominal pain or diarrhea. what happens when she eats? remember i mentioned we are interested in the patient's response to what is happening to them.
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no information provided. at 75 with osteoarthritis and lumbar disc disorder i would have expected to see problems with mobility. were there?
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you should be looking up and reading about every medical disease and condition listed in her history even if you haven't studied it yet in class. now, that you know a hiatus hernia was found on endoscopy, definitely look that up. you need to know the pathophysiology for the etiology of any nursing diagnoses that might be related to your patient's response to this. you also need to see the signs, symptoms and complications and if you missed seeing any of them in your patient so that you can correct this for your care plan.
- http://www.merck.com/mmpe/sec02/ch012/ch012h.html - hiatus hernia
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - none mentioned. although the doctor may not have clearly stated anything in the chart about her condition, the treatments the doctor has ordered are clues for us to pick up on what is going on. ask yourself why she is getting this med or that treatment. there is a reason. dig around for it or use your best educated guess based on what you know about her history.

step #2 - determine the problem(s). this is where you analyze the data you collected above. some of the data will be normal and some abnormal. when things are normal that means everything is ok. stuff that is abnormal is evidence that something is wrong--a problem is in the wind. and we are looking for problems, specifically, nursing problems. so, we want to list out anything that is abnormal about the assessment. for nursing it can be a physical symptom and it can be behavioral things as well as problems getting adls accomplished.

these things become your list of signs and symptoms that will determine what nursing problems you have. there may be more than one symptoms of a problem or perhaps just one symptom of a problem. it is your job to make the classification and then apply the names (nursing diagnoses) to them.

i can't really help you here because you just didn't supply any assessment information except for the "hopefully, there's nothing wrong with me" and i honestly don't know what to do with that statement.

step #3 - planning. write goals/outcomes and nursing interventions. this is where you get into the your strategies to do something about the problems. it is also why you will find the assessment information so important. just as a physician targets his treatments at the cause and symptoms of a person's disease, we target our nursing interventions at the signs and symptoms of each nursing problem. it is not always possible to target the etiology of the problem, but do so when possible.

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regarding the nursing diagnoses you came up with:

1.)anxiety related to pain and uncertainty of cause or outcome of condition aeb stated "hopefully, there's nothing wrong with me."

a diagnosis of anxiety would never be sequenced before a diagnosis of acute pain.
pain is a symptom of this diagnosis, not a related factor. and if she's having abdominal pain, it should be split off into it's own nursing diagnosis.

2.)acute pain r/t ????

acute pain - definition: unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (international association for the study of pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. (page 354, nanda international nursing diagnoses: definitions and classifications 2009-2011)
read about the pathophysiology of a hiatus hernia, gi reflux and the symptoms of diarrhea and you will find what you need to put for your related factor.

3.)

i think you will find this one if you do a more thorough assessment and look at her adls.

4)risk for fluid volume deficit r/t frequent loose stool.

if she is actually having diarrhea, there is a nursing diagnosis for that.

surviveslu · Jan 31, 2010

I have a similar case. Maybe someone can give a suggestion based on your expertise.

62y/o woman hx diabetes. Takes combo drug actos/metformin, lipitor, avapro and januvia on a daily basis. She also drinks garlic juice, aloe vera juice and the socalled reishi (reshid) mushroom. She takes multivitamins and calcium tablets. She exercises regularly but c/o stomach pain 5/10. She is awaken by her stomach cramps at 10PM, 1AM and 3AM. Her stomach pain is only at nighttime. The pain is upper epigastric area to slight below midsternal area. A recent CTscan with contrast (barium drink and IV iodine) came up with just some small liver nodules, so small that it is not characterized. Yet she still c/o of stomach pain during the night. What additional information should I find out from this patient?