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Nursing Diagnosis Help

Posted

hello all,

i am in need of help with a nursing diagnosis.

below is my information. nothing is abnormal and i don't know what a good nursing diagnosis would be. could you please help? thank you for your time.

abdomen

client: 22 year old female college student denies allergies to medication, food or environment. admits to use of tylenol sparingly for migraine headaches.

subjective data:

abdomen: ct denies any change in appetite, difficulty in swallowing, food intolerance, abdominal pain, nausea/vomiting. denies change in bowel habits. ct denies any history of g.i. problems, jaundice, colitis, hepatitis, or abdominal surgery. currently takes tylenol sparingly with headaches, does not consume alcohol or smoke.

objective data:

abdomen: upon inspection abdomen skin is smooth and warm to touch, no lesions, moles present. umbilicus is midline and inverted. contour of abdomen is flat, abdomen is also symmetric. bowel sounds present in llq, rlq. percussion of abdomen yielded no pain or tenderness. liver measures 6cm. palpated abdomen with light and deep palpation to yield no pain or tenderness. cva tenderness not present.