Just want to run my data and nsg dx's by you. Please critique!

Esme12, ASN, BSN, RN · Apr 20, 2014

1.Risk for Pain related to recent surgery as evidenced by complaint of back pain with turning and positioning,as well as shoulder pain with activity.
2.Risk for skin breakdown due to impaired musculo-skeletal activity as evidenced by inability to turn and position self,as well as to activity intolerance.

If the patient is complaining about having pain it is no longer a risk is it? AND.....According to NANDA I there is NO AT RISK for pain diagnosis

lwandel · Apr 20, 2014

You're correct Isis, that's why I was struggling with using pain as a ndx. She only c/o pain with movement, otherwise she denied pain or her levels were 1-2/10.

I am still working on this particular care plan, but the dxs I think I'm using are:

1. Imbalanced Nurtrition: less than body requirements r/t gastritis AEB abdominal pain, aversion to eating, low BMI, and poor muscle tone.

2. Constipation r/t decreased motility of GI tract and insufficient physical activity AEB straining with defecation, inability to pass stool, abdominal tenderness, anorexia, generalized fatigue and hard, formed stool.

3. Adult failure to thrive r/t fatigue AEB anorexia, unintentional weight loss of 15% in less than 6 months, evidence of fatigue, physical decline, and dehydration.

How do these sound to you? I would love another opinion!

Thanks,

~leslie

Isis Phoenix · Apr 20, 2014

Thanks.....I like your comment, however I would like to point out that the complaint of pain is made upon turning, and positioning (facial grimacing, etc.)...in other words with activity.

If a patient is post-surgery, pain is a diagnosis....the fact that the above patient was admitted from home tells us that she had surgery some time ago...we are not sure of the time frame, so we cannot determine if this is acute, or chronic pain until we have more information. Thanks for sharing your knowledge.

“I am a woman in process. I'm just trying like everybody else. I try to take every conflict, every experience, and learn from it. Life is never dull.”

Oprah Winfrey

nurseprnRN, BSN, RN · Apr 20, 2014

She has pain when she isn't lying still, i.e., when she tries to use her shoulder. That counts as pain, and you can determine whether it's acute (like postop) or chronic) generally defined as >12 weeks or beyond normal expected time for the procedure.