Help writing 10 Nursing Diagnosis

[estef, BSN, RN]

I really need so much help.

I am having a hard time coming up with diagnosis for this patient.

30y/o female

PMH: hyperthyroidism, colycystitis

PSH: thyroidectomy, cholecytectomy,

Chief complain: abdominal pain

ERCP w/ stent was done during this hospitalization

meds:

Synthroid

Protonix

Bactroban nasal ointment

Zosyn

Dilaudid

Reylan

NaCl IV 75ml/h

HR:64

RR:16

BP:109/75

Pulse ox: 100

temp: 97.4

pain 0/10

66kg 5'5''

Upper right quadrant of Abdomen tender upon palpation, pain 5/10

pt states she takes calcium supplements and OsCal, does not eat red meat,

alert and oriented, ADLs self

mother of 3 children

sexually active but does not use condoms or birth control.

Spanish first language, speaks short phrases in english

Knows what medicine she is taking but does not know what each is for or side effects

So far i have:

risk for excess fluid volume R/t iv therapy

deficit knowledge r/t medication regimen AEB inability to recall medicine and their purpose

Risk for acute pain r/t tissue trauma secondary to ERCP

risk for Hypercalcemia r/t excessive calcium supplements intake.

impaired verbal communication r/t language barrier aeb patient asking spanish speaking staff what the doctor had said. (is there a different wording for Impared verbal communication or different diagnosis?)

Can there be more than deficit knowledge diagnosis.( the patient doesnt know much about the complications of thyroidectomy. )

i am really unsure of this diagnosis please help. i need 10 diagnosis

thank you

[MrsMig, BSN, RN]

Ten seems excessive? Yikes...we only have to do 3 priorities w/intervention & outcomes...

Anyhow, I think you are on the right track and I also think it's okay to have than 1 knowledge deficit as long as it doesn't pertain to the same dx.

Also, I'd place pain as your priority...

Here's a few:

Impaired skin intergrity R/T abdominal incision;

Ineffective denial R/T to anxiety;

Risk for infection R/T surgical incision;

Family processes R/T power sift of family members (i.e. mom being in hospital and not home)

Oh and since she's on tons of meds and lowered mobility and abdominal surgery

Risk for constipation R/T (meds, surgery) whatever...

Here's a few I could think of....GL....

[UumiNurseX]

What does the patient's lab values look like? You can always come up with a dx from those.