Hello! I'm currently doing my second NCP in my Nursing life. I really don't have any idea on how to do it up until now. So please help me. I'm having problems finding the diagnosis of my patient. I need 2 actual problems now. Btw, this is due this afternoon. So please, I would really appreciate it if you'll lend a hand.
Here's the scenario:
My patient is having problems defecating because she has an episiotomy. She's a primigravida and she's 18y/o. It has been 4 days since she had delivered but she is stil not passed stools, only flatulence. She also complained of 7/10 pain in the episiotomy site.
What could be the appropriate and NANDA approved diagnosis for this one? Thank you very much!
Umm....ok only bc I just completed the first of a 4 day rotation on OB and I am still a student, and this sort of happened but more related to C-Section...
1. Do you have a Nursing Dx text? Ours is "Handbook of Nursing Diagnosis: Application to Clinical Practice" (Carpenito-Moyet, 12 & 13 Ed). Either that or go do www.nanda.org to get a reputable nursing diag. text. This will line out for you by body system/functional health pattern currently approved NANDA diagnoses.
2. If your pt isn't poopin' and it's been a while (longer than facility expectation), its an actual diagnosis that comprises 3 parts: Diagnosis, related to....., as evidenced by: XXX.. For Example: Constipation related to immobility secondary to acute pain, caesarean section AEB lack of bowel movement or flatus. Alternatively, "Constipation r/t episotomy pain AEB client states, "I can't push, it hurts too much to poop" and lack of BM for 3 days."
3. If your pt is just a few hours or so out of surgery, then it's likely a "risk for" Dx as in: Risk for constipation r/t lack of peristalsis secondary to anesthesia, immobililty, etc. NOTE! In RISK FOR diagnoses, you have NO "AS EVIDENCED BY (AEB)" because you suspect a potential diagnosis based on the situation (but you have no real signs/symptoms...yet!). WHEN you get actual s/s, then it can become a true Nursing DX (See #1 above)
4. And lastly....oh do i FEEL YOUR PAIN, I struggle/struggled with this A LOT!....I found that looking for the broadest NDx then allowed me multiple interventions that could be used to further refine NDx as pt care progressed.
Risk for infection would be another important diagnosis. Acute pain is another one. Is this a 1st, 2nd, or 3rd degree incision? You need some nursing interventions as well, what will you do to help her? Perhaps call and get an order for stool softeners, should be ordered for her already. Ice pack to relieve the pain? Encourage ambulation? Think about it!
They still teach this NANDA crap in school? Talk about a total disjoint with reality....
Who ever came on to the floor and said, "Wait, I have to read the nursing diagnoses before I jump in and do the obvious with my too-big assignment today!"
They still teach this NANDA crap in school? Talk about a total disjoint with reality....
Who ever came on to the floor and said, "Wait, I have to read the nursing diagnoses before I jump in and do the obvious with my too-big assignment today!"
Of course they are! That's how students learn. As you well know, AFTER you become a nurse and write care plans, most of the are computerized, but a student couldn't learn that way.
First off she isnt constipated because of the episiotomy. She can be constipated obviously from the pain meds shes been receiving postpartum or even in l&d, but she didnt become constipated purely because she received an episiotomy!
Try acute pain r/t episiotomy aeb pain 7/10.
As for the constipation, its more than likely r/t pain meds given postpartum or even in l&d. So saying perceived constipation r/t pain medication received aeb no stool passed in 3+ days as stated by pt would be better than saying just plain constipation or that an perineal incision is caused by it. What I consider constipation can be completely different than what another person considers constipation... so saying perceived constipation will more than likely let your instructor know that you arent diagnosing but you arent ignoring that youre pt hasnt pooped in 3 or 4 days.
And if you are just bend on saying constipation r/t incision, at least put fear of defecation r/t episiotomy pain aeb pt stating it will hurt to poop.
K Im done! Hope you figure this out, or go buy a book.... no one wants to do your homework for you when we've all done this ourselves already!
So please help me. I'm having problems finding the diagnosis of my patient. I need 2 actual problems now. Btw, this is due this afternoon. 
Tama Conchinati
6 Posts
H0P3, thanks a lot!
I changed it to: Constipation related to 7/10 pain on episiotomy site.
Thanks a lot!