Nursing Diagnosis conflict help!

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Help me out if you can! I'm at disagreement with my teacher over what the nursing diagnosis is for the patient below. Now I don't want to give the answer away for fear of revealing to much, but I promise that I've already faced the repercussions for the Nursing Diagnosis that I made. Thank you for your input and I look forward to your response.

Thanks, E

Mrs. S. is a 28 y.o. African American female admitted to your floor with c/o RUQ (Right upper quadrant) abdominal pain, fever, and Rt. Shoulder pain. Mrs. S. states this started gradually 2 days ago but got worst last night. She rates the pain 9/10 and describes it as an aching pain that is constant. She denies any activity that could of brought it on. It is worst when she rides in a car and goes over bumps in the road. Mrs. S. tried taking Ibuprofen 200mg every 4 hours for the pain with slight relief. Her PMH includes Hypertension. Her current medications include Norvasc 5mg everyday & Lotensin 20mg everyday. Her LMP (last menstrual period) was 1/1/08. Her husband is away in Iraqand she has not been sexually active for 4 months since he was last home. Mrs. S. denies smoking cigarettes or using drugs. She admits to an occasional glass of wine. She was given Demerol 75mg and Phenergan 25mg IM in the ER about 2 hours ago. Her pain has decreased to a 6/10. The ER physician has her scheduled for an ultrasound of the abdomen. Her recent blood work in the ER showed to be normal except for an elevated WBC (white blood cell count) of 15. Her VS are 100.1, 85, 12, & 140/70. Wt. 205# & Ht. 5'5” Lungs are clear to auscultation & percussion. Heart is regular rate with normal S1 & S2. Abdomen is tender over the RUQ with guarding. Bowel sounds are present x 4 quadrants

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Specializes in Urology.

so what was the nursing diagnosis you made? Not sure how you would "giving away too much" since you state you got it wrong?!

Ohh and I dont think anyone here wants to do YOUR homework!

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Specializes in Infusion Nursing, Home Health Infusion.

You have to state what your musing diagnoses are in order for us to comment !!!

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Hyperthermia related to illness, as evidenced by Vital Sign 100.1 Fahrenheit and patient complaint of fever.

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Specializes in ICU.

Pain management is #1

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Specializes in Critical Care.

If she's 28 and her last menstrual cycle was 8 years ago, that would seem to be an issue as well, but 100.1 is barely hyperthermic. Normal circadian rhythms can produce a temperature range that goes up to 100 in a completely healthy person.

What are patient's symptoms included in the question, for instance, why did they get 25mg phenergan in the ER?

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Sorry, my teacher is using old Case Studies. She said on the discussion board when I asked her "assume her last menstruation was a month ago"

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Specializes in Critical care.

Temperature isn't a big concern, and technically isn't a fever, until it is 100.5 degrees or higher. I agree with others it's not a top priority, especially since it's technically not even a fever. I agree that pain is the number one. Looking at the BP it is high, and assuming she is compliant with her BP meds and normally controlled while on them, it's pretty safe to assume the high BP is a result of the pain. My SBP is normally around 110. I had a muscle spasm in my back recently which was incredibly painful and my BP shot up to close to 140.

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She must have asked for it. I'm guessing nausea.

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Emantsch said:
Hyperthermia related to illness, as evidenced by Vital Sign 100.1 Fahrenheit and patient complaint of fever.

Hyperthermia could be a DX, however it is not the main one. What is the CAUSE of the hyperthermia? In this case.. I would go with acute pain and risk for infection.

Best of luck with your studies.

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twozer0 said:
so what was the nursing diagnosis you made? Not sure how you would "giving away too much" since you state you got it wrong?!

Ohh and I don't think anyone here wants to do YOUR homework!

Eating the young , before they are hatched. I have no problem guiding a student . It's called mentoring.

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Emantsch said:
She must have asked for it. I'm guessing nausea.

No guessing allowed. In this case, phenergan is a potentiate.

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