hello everybody,

i'm new to this forum, and i'm a nursing student.

i have had the lessons about the nursing diagnosis and (pes) format,

but i'm kinda confuse and having a trouble with cases studies that i need to write

nursing diagnosis, and then write it up in pes format!!

so, if any one ready to help me, just let me no asap, and i'll try to bring some examples so that we do them together here!

thanks,

Hi and welcome to the site

Will move this to the nursing student assist forum for further input

we can't give you anything specific without patient information. you can see more information about nursing diagnosis, pes format, and examples of diagnosing and pes formatting of nursing diagnostic statements on this thread:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

oops, I couldn't find that forum, so I put here. anyway, thanks for informing me of that mis Silverdragon102

ok, mis Daytonite thanks for being here, I'll put the case study that I have today, later afternoon, and we could work it out then.

and then I'll compare what I got now to what you guys gonna do !

thanks,

okay, here is the case study, it's kinda long one, but...

42 year old female client comes to the clinic with a medical diagnosis of urinary tract infection. She is a real estate agent and is particularly concerned because she has been experiencing involuntary passage of urine. She states she has always been able to delay urination until she had time to find a restroom. "In my business, that is essential. I can't be running to the restroom every little bit while I am showing buyers all over town." She states she has been voiding hourly. She is complaining of lower abdominal pain with a sensation of cramping and burning with urination.

She tells you that her pain is terrible. She appears listless and her face is drawn into a permanent scowl. The client says she hopes she will get extra rest since she feels so tired. Upon further questioning, she reports she usually slept 8 hours per night, but lately she has been having difficulty going to sleep. " I guess I know I'm going to be up all night." She sleeps only 2-4 hours at a time and invariably awakes at 5:30 a.m. when in the past she would sleep until 7:00 a.m. You note dark circles under her eyes and a mild tremor of her hands. She asks numerous questions about everything that is done to or for her. She is restless and states she feels shaky. She speaks rapidly and keeps asking questions for reassurance that she will fully recover.

She lives with her husband and four children ages 19, 17, 14, and 10. She has been married 21 years and has close relationship with her husband and children. She and her husband have belonged to the same Baptist church for their entire marriage and go to church every Sunday.

BD states she felt nauseated and too upset to eat today. She has lost 10 pounds in the past three weeks. In the past month, she has had heartburn at least once per day. Because of her busy schedule she admits her eating habits are poor and skips meals "a lot". She has had some problems with her bowel movements. She states that some days she has abdominal distension with constipation and other days has diarrhea. No history of cardiac or respiratory problems. She denies chest pain, palpitations or tachycardia. Smokes 1 pack of cigarettes per day for the last 23 years. She states every morning her nose is "stuffy" until she takes a shower. Occasionally she has a "sinus" headache. She denies any seasonal or medication allergies.

Physical Assessment:

HT: 5'6" WT: 115 lbs. T: 101.2 P: 94 R: 22 BP: 132/82

Neuro: Orientated to time, person and place, cranial nerves intact. Reflexes +1

EENT: Bilateral PERRLA, sclera white, conjunctiva pink. TM's mobile. Mild sinus tenderness with palpation. Nasal mucosa congested. Pharynx clear no exudates. No enlarged cervical nodes. Mucous membranes: moist, no lesions

Lungs: Clear, no rales, rhonchi or wheezing

Cardiac: Apical rate regular, no etopic beats, peripheral pulses +2

Abdomen: Soft, active bowel sounds, no CVA tenderness, tenderness with palpation of super pubic area

Peripheral: No peripheral edema bilaterally,fine muscle tremors bilateral hands, full ROM all joints, equal grasp strength, stable gait, Romberg (-)

now, what I need to do is to put the assessment for ELIMINATION PATTERN.

so, first, I put the assessment, then the nursing diagnosis in PES Format, and finally the expected outcome.

so, I'll come later and check if anyone put answers, I'll put my answer and see if it's correct!

thanks

what i need to do is to put the assessment for elimination pattern. so, first, i put the assessment, then the nursing diagnosis in pes format, and finally the expected outcome.

assessment:

• medical diagnosis of urinary tract infection
  
• temp 102.2
  
• pulse 94
  
• she has been experiencing involuntary passage of urine
  
• states she has always been able to delay urination until she had time to find a restroom
  
• states, "i can't be running to the restroom every little bit while i am showing buyers all over town." she states she has been voiding hourly. she is complaining of lower abdominal pain with a sensation of cramping and burning with urination.
  
• she tells you that her pain is terrible.
  
• she appears listless and her face is drawn into a permanent scowl.
  
• she has had some problems with her bowel movements. she states that some days she has abdominal distension with constipation and other days has diarrhea.

nursing diagnoses (in pes format):

• impaired urinary elimination r/t urinary tract infection aeb involuntary passage of urine, need to void hourly, and complaint of terrible lower abdominal pain with a sensation of cramping and burning with urination.
  
• constipation r/t irregular eating habits aeb abdominal distension and days where she has constipation and other days of diarrhea.

in order to do outcomes you need to know what your nursing interventions are going to be for these two diagnoses. interventions are based upon the evidence that supports the patient's problem and how you are going to treat it.

for the first problem. . .impaired urinary elimination r/t urinary tract infection aeb involuntary passage of urine, need to void hourly, and complaint of terrible lower abdominal pain with a sensation of cramping and burning with urination, you would focus your nursing interventions on the following:

• involuntary passage of urine (incontinence)
  
• needs to void hourly (frequency)
  
• complaining of terrible lower abdominal pain, cramping and burning with urination (dysuria)
  
• see https://allnurses.com/forums/2756543-post13.html

outcomes are what you predict will happen as a result of your interventions. i am leaving the interventions and outcomes for you to determine and write.

for the second problem. . .constipation r/t irregular eating habits aeb abdominal distension and days where she has constipation and other days of diarrhea, you would focus your nursing interventions on the following:

• irregular eating habits
  
• the constipation
  
• the diarrhea

as part of my interventions i would attempt to determine if there are specific foods that bring on the constipation or diarrhea. again, outcomes are what you predict will happen as a result of your interventions. i am leaving the interventions and outcomes for you to determine and write.