nursing diagnosis to use for breast tenderness

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i really dunno what to do.:banghead: i have to do this for tomorrow.:cry: what nursing diagnosis should i use if the client have breast tenderness associated with period for most of her adult life? the objective datas are round, tender, mobile, everted masses w? smooth borders in all quadrants. the nipples are everted, round, and free of lesions. the breasts are symmetric in shape and contour. please halp! i'd really appreciate it! :specs:

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Another word for tenderness is .......?

That's your answer.

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Specializes in Med Surg, LTC, Home Health.

Powerlessness

Knowledge Deficit

Anxiety

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Alteration in comfort

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Specializes in ICU, Telemetry.

disturbed body image

chronic pain

ineffective sexuality pattern

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

please post in the nursing student assistance forum (https://allnurses.com/forums/f205/) where i can find your questions much faster. you will also get help from other students there.

when care planning you should follow the nursing process:

  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)
    • 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.

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 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 - the doctor already diagnosed this:

  • breast tenderness associated with period

that is a very generic diagnosis. in fact, it is a symptom: tenderness. when doctors do this, it means they don't know what the problem is either. more assessment and examination might be needed. what you can do is look up information about menstruation and breast tenderness associated with it.

keep in mind that the information that is going to be most helpful to you is what you will need as a nurse. we treat the patient's nursing needs, not their medical needs. i think the patient needs some education about menstruation and maybe a more thorough assessment of this pain and how it has changed, if at all, recently. i would assume, however, that the doctor already addressed that.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - the only abnormal data is that the breasts are tender when the patient is menstruating.

  • tenderness

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - this is a matter of choice. i think it is a knowledge problem.

  • deficient knowledge, menstrual symptoms related to lack of information as evidenced by complaint of breast tenderness with her period throughout her adult life.

but this is another possibility:

  • chronic pain related to hormonal changes and water retention during menstruation as evidenced by complaint of breast tenderness with her period throughout her adult life.

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