Nursing diagnosis: please read

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we were given by our teacher an assignment on how to make NCP.. but i really don't know how since this will be my first time to make one.. The chief complaint of the patient is on and off severe abdominal pain.. her laboratory exams are okay but she describes her health as poor after admission to the hospital... she is on NPO for the past 12 hours... she has no problems in urination and bowel movement but she has not had any BM since admission.. she rates pain as 10 on a scale of 0-10.. she has not been given any pain medication since she is suspected to have appendicitis.. she is anxious about her office in coping without her.. her husband is very attentive to her needs and her relatives also vist her. she feels that her hospitalization is stressful.. she has also no mobility problems.. she regrets not having any children... what could be the possible NURSING DIAGNOSES to this situation?? PLEASE HELP...

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is this a case study or did you actually take care of this pt?

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Specializes in Intensive Care and Cardiology.

I would go with the pain or anxiety.

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.

Alt in comfort r/t pain;

Potential/actual alt in nutritional status r/t decreased nutrition/NPO :

Potential alt in fluid and electrolyte status r/t same as prior:

Alt in GI status 2/2 NPO, decreased nutrition, no BM.

Difficulty coping with illness/hospitalization.

Anxiety r/t uncontrolled pain.

knowledge defecit r/t education of tests/procedures/ pain management.

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Specializes in Advanced Practice, surgery.

Will move to student assistance forum

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to s_le2006 this is not a case study and i did not have any contact with the patient... this were given to us in preparation for the actual NCP making...

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to GrumpyRN63 thank you for the response... it is really a great help to me as a beginner... hope you can help me more in the NCP making...:)

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.
to GrumpyRN63 thank you for the response... it is really a great help to me as a beginner... hope you can help me more in the NCP making...:)

Your welcome, I would be glad to help although it's been a century since I did one, I'm sure they aren't 20 pages long anymore (I kid you not),which may have left me with selective amnesia !!! best of luck, Grumpy

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Specializes in med/surg, telemetry, IV therapy, mgmt.

the nursing process which is a problem solving method should be used to help you write a care plan. it has 5 steps that you must follow in sequence:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

you cannot begin to diagnose until you have completed your assessment of this patient and analyzed the data you have collected. i also want to point out to you that a nursing diagnosis is not quite the same as a nursing problem. a nursing diagnosis is a label, or shortened tag, for a much longer and more accurate description and definition of the nursing problem. this is why you need a nursing diagnosis reference book with nanda taxonomy information in it. the cheapest source available comes directly from nanda itself: nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95.

when doctors diagnose a patient, they take a history, do a review of body systems, do a physical examination, and order a battery of tests. they take a look at all the data they collected and specifically consider what was abnormal to come up with their medical decision. a plumber or auto mechanic works in much the same way using the knowledge and skills of their trade. a diagnosis is nothing more than the resulting decision or opinion after the process of examination or investigation of the facts. a nursing diagnosis is no different. as a student, your process of examination or investigation of the facts includes the following:

  • a physical assessment of the patient
  • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
  • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
  • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

if this is not a real patient, you obviously can't do an actual physical exam or look in a real chart, but you can find information about the disease or condition that was provided for you as well as include the signs and symptoms that scenario gave to you. assessing is very much like being a detective looking for clues. in order for a detective to say a crime was committed there must be evidence of the crime; in order for a nurse to say a nursing problem exists there must be symptoms of this nursing problem. if you are told a patient has a specific disease or condition you should start breaking it down into its signs and symptoms and looking for them in the patient.

from what you posted, the patient has these symptoms which are the evidence that will support nursing problems that this patient has:

  • severe abdominal pain with pain rated as 10 on a scale of 0-10
  • not had any bm since admission (how long is that?)
  • anxious about her office in coping without her
  • stressed about being hospitalized
  • regrets not having any children (i'm not sure why this would even be important)

because her medical diagnosis is appendicitis you need to look up this medical condition, its pathophysiology, signs/symptoms, usual tests that are ordered to diagnose it, the medical treatment for it including the expected consequences during the healing phase, and potential complications. you need to read about appendicitis and appendectomy in your nursing textbook:

complications include: peritonitis, fecal fistula, intestinal obstruction and death.

once you have completed assessing and learning all you can about appendicitis and its treatment then you can move on to diagnosing the patient.

there are currently 188 nursing diagnoses. every one of them has a definition that more accurately describes what the diagnosis label only hints at. every diagnosis also has a list of defining characteristics, or symptoms, that are the evidence you need to prove the problem exists. the patient's problem must fit with the definition of the diagnosis and must have one or more of the defining characteristics. the patient should also have at least one of the related factors, or etiologies, that are the underlying cause of the nursing problem as well.

if this patient is suspected of having an appendicitis, she is going to be kept npo in anticipation of surgery. appendicitis is a serious condition because at any time the appendix could rupture and cause abdominal-wide infection. the swelling due to the inflammation of the appendix can also cause obstruction and ileus of the bowel. if ileus occurs, fluid and electrolyte imbalances start to happen. this patient is most likely going to be having a ct of the abdomen and an abdominal ultrasound. cbc will be done and the white cell count will probably be elevated indicating inflammation is present. she will be started on iv fluids and iv antibiotics.

in order of priority:

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Specializes in Critcal Care.

Chronic Pain

Altered elmination

Altered nutrition: Less than body requirements

Anxiety r/t hospitalization

Regret/Depression r/t life choices

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i forgot to place that the patient has a low WBC count...

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.

How low?, wnl's or below nl/neutropenic???

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