So....I have a patient with FAP who is in for her 22nd GI surgery. I've covered the big issues, pain & anxiety in other diagnostic statements, but I'm stuck on this one. It appears to me that imbalanced nutrition is a big problem for this lady. Her labs are borderline normal-low, she has lost (by her claim) 70 pounds this year, has horrible GI problems, and has no teeth.
How do I write this up? I have this:
Imbalanced nutrition (less than body requirements) r/t abdominal pain and difficulty masticating foods as evidenced by patient's pain rating and lack of teeth.
I have to write the r/t as something that an RN can do something about, so I can't say it's r/t the fact that this woman has a series of GI diseases that affect her ability to absorb nutrition.
Any advice?
Thanks!
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So....I have a patient with FAP who is in for her 22nd
GI surgery. I've covered the big issues, pain & anxiety in other diagnostic statements, but I'm stuck on this one. It appears to me that imbalanced nutrition is a big problem for this lady. Her labs are borderline normal-low, she has lost (by her claim) 70 pounds this year, has horrible GI problems, and has no teeth.
How do I write this up? I have this:
Imbalanced nutrition (less than body requirements) r/t abdominal pain and difficulty masticating foods as evidenced by patient's pain rating and lack of teeth.
I have to write the r/t as something that an RN can do something about, so I can't say it's r/t the fact that this woman has a series of GI diseases that affect her ability to absorb nutrition.
Any advice?
Thanks!