Please help with nursing diagnosis

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Hi everyone, I have my first "real" patient and I am working on my nursing diagnosis. I need 3. Here is what I have, I know it's a little "rookie", but like I said, my very first one. My patient is a 30 yr w f who came to the ER with c/o N/V/D (4-5 loose, watery stools a day), lower left ab pain constant rated at 7-8, no fever, no bloody stools. She has admitting diagnosis of Enteritis. Here are my 3 :

  1. Chronic pain possibly r/t inflammation of intestines aeb pt states "my stomach hurts right here" pointing to lower left abdomin.
  2. Diarrhea r/t inflammation of bowel aeb (okay here I am having trouble - would it be aeb watery stools, or CT scan showing inflammation? or either?)
  3. Next problem here - Impaired nutrition r/t vomiting ~or~ Nutrition deficit r/t vomiting......then how do I finish that? Do I say aeb throwing up? I know that can't be right, but what should it be. Her s & s is vomiting.

I am clueless right now. Any help or suggestions will be greatly appreciated!!!! Thanks!!!!!

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Did she say that she had been eating less due to the n/v/d? if so you can use her deminished intake for the nutrition

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no, she wasn't very vocal. She was doped up and sleeping for most of the day.

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Specializes in Orthopedic, Corrections.

Maybe

Acute pain r/t inflamed bowel manifested by 7/10 pain

Nutrition deficit r/t inflamed bowel manifested by N/V/D

Fluid volume deficit (dehydration) r/t N/V/D manifested by dark urine or labs that are off, tenting skn?

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

did you follow the nursing process to help you keep organized and do all work required in problem solving this? did you sit down and go through your assessment data? did you look up the signs and symptoms of enteritis, inflammation, nausea, diarrhea, and pain to make sure that you didn't accidentally miss any of the symptoms of them in your patient? did you use a nursing diagnosis reference to help you with the diagnosing?

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

  • enteritis
  • n/v/d
  • ct scan showing inflammation

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - why is this chronic pain as opposed to acute pain? if it is a chronic pain that the patient has been living with for over 6 months (the definition of chronic pain) why should it be a priority over diarrhea which is depleting the patient of fluids and electrolytes?

  • 4-5 loose, watery stools a day
  • lower left ab pain constant rated at 7-8
  • "my stomach hurts right here" pointing to lower left abdomen

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

  • imbalanced nutrition: less than body requirements r/t inability to absorb food aeb [evidence, especially if patient has lost weight]
  • diarrhea r/t inflammation of bowel aeb 4-5 loose, watery stools a day and lower left abdomen pain
  • chronic pain r/t increased peristalsis aeb constant lower left abdominal pain rated at 7-8 and patient's statement that "my stomach hurts right here" while pointing to lower left abdomen.
  • deficient knowledge, disease management r/t lack of information aeb [evidence of patient's lack of information about how to control their disease]

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Specializes in Orthopedic, Corrections.

What does AEB stand for? Thanks

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Specializes in med/surg, telemetry, IV therapy, mgmt.
What does AEB stand for? Thanks

As Evidenced By. It means the same thing as Manifested By.

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did you follow the nursing process to help you keep organized and do all work required in problem solving this? did you sit down and go through your assessment data? did you look up the signs and symptoms of enteritis, inflammation, nausea, diarrhea, and pain to make sure that you didn't accidentally miss any of the symptoms of them in your patient? did you use a nursing diagnosis reference to help you with the diagnosing?

i did use the nursing process (as best as i knew how), and i have reviewed my assessment data, i sat and talked with my patient for quite a while today, and i have all of her symptoms in my assessment. i have studied up on enteritis, and actually through the studying i thought this may be chron's disease, but the diagnosis from the chart didn't mention it. the pt. has no bloody stools, and she has constipation and diarrhea, which puzzled me at first, and the more research i did found that one reason for that could be inflammation and not allowing the formed (harder) stools to pass and only allow the watery stools to get by, which lead me to crohn's terminal ileitis where a small intestinal obstruction can occur. this morning they told her she may have crohn's disease, which she failed to tell there is a family hx of. i used my doenges nursing diagnosis manual for help with the diagnosing.

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

  • enteritis
  • n/v/d
  • ct scan showing inflammation

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - why is this chronic pain as opposed to acute pain? if it is a chronic pain that the patient has been living with for over 6 months (the definition of chronic pain) why should it be a priority over diarrhea which is depleting the patient of fluids and electrolytes?

i didn't mean to put chronic, it's acute. i have no idea why i typed that. :confused: this has been going on for about 2 months and she just sought help 7 days ago.

  • 4-5 loose, watery stools a day
  • lower left ab pain constant rated at 7-8
  • "my stomach hurts right here" pointing to lower left abdomen

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

  • imbalanced nutrition: less than body requirements r/t inability to absorb food aeb [evidence, especially if patient has lost weight]
  • diarrhea r/t inflammation of bowel aeb 4-5 loose, watery stools a day and lower left abdomen pain
  • chronic pain r/t increased peristalsis aeb constant lower left abdominal pain rated at 7-8 and patient's statement that "my stomach hurts right here" while pointing to lower left abdomen.
  • deficient knowledge, disease management r/t lack of information aeb [evidence of patient's lack of information about how to control their disease]

there is no i&o record on this patient. i asked the question today, "should this not be done?" the nurse never really answered my question. she said something to the effect that the doc hadn't mentioned it. i responded by saying if the patient isn't eating or drinking, is n/v/d, shouldn't she be"? there was a note placed in the chart later that day to start monitoring i&o.

for the diarrhea nd above, is the rational for r/t inflammation of the bowel okay to use b/c of the ct scan revealing that information?

thank you so much for your help!!! sometimes just "talking" it out with someone that knows much more clarifies things! thanks again!!!

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

for the diarrhea nd above, is the rational for r/t inflammation of the bowel okay to use b/c of the ct scan revealing that information?

yes. also, since you have documentation in the chart of "enteritis" by the doctor and now "crohn's", you are definitely safe to say there is inflammation in the bowel.

you did good!

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did you follow the nursing process to help you keep organized and do all work required in problem solving this? did you sit down and go through your assessment data? did you look up the signs and symptoms of enteritis, inflammation, nausea, diarrhea, and pain to make sure that you didn't accidentally miss any of the symptoms of them in your patient? did you use a nursing diagnosis reference to help you with the diagnosing?

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

  • enteritis
  • n/v/d
  • ct scan showing inflammation

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - why is this chronic pain as opposed to acute pain? if it is a chronic pain that the patient has been living with for over 6 months (the definition of chronic pain) why should it be a priority over diarrhea which is depleting the patient of fluids and electrolytes?

  • 4-5 loose, watery stools a day
  • lower left ab pain constant rated at 7-8
  • "my stomach hurts right here" pointing to lower left abdomen

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

  • imbalanced nutrition: less than body requirements r/t inability to absorb food aeb [evidence, especially if patient has lost weight]
  • diarrhea r/t inflammation of bowel aeb 4-5 loose, watery stools a day and lower left abdomen pain
  • chronic pain r/t increased peristalsis aeb constant lower left abdominal pain rated at 7-8 and patient's statement that "my stomach hurts right here" while pointing to lower left abdomen.
  • deficient knowledge, disease management r/t lack of information aeb [evidence of patient's lack of information about how to control their disease]

for the diarrhea nd above, is the rational for r/t inflammation of the bowel okay to use b/c of the ct scan revealing that information?

yes. also, since you have documentation in the chart of "enteritis" by the doctor and now "crohn's", you are definitely safe to say there is inflammation in the bowel.

you did good!

thanks.....you helped my confidence out!!!

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Hi everyone I have my first "real" patient and I am working on my nursing diagnosis. I need 3. Here is what I have, I know it's a little "rookie", but like I said, my very first one. My patient is a 30 yr w f who came to the ER with c/o N/V/D (4-5 loose, watery stools a day), lower left ab pain constant rated at 7-8, no fever, no bloody stools. She has admitting diagnosis of Enteritis. Here are my 3 :
  1. Chronic pain possibly r/t inflammation of intestines aeb pt states "my stomach hurts right here" pointing to lower left abdomin.
  2. Diarrhea r/t inflammation of bowel aeb (okay here I am having trouble - would it be aeb watery stools, or CT scan showing inflammation? or either?)
  3. Next problem here - Impaired nutrition r/t vomiting ~or~ Nutrition deficit r/t vomiting......then how do I finish that? Do I say aeb throwing up? I know that can't be right, but what should it be. Her s & s is vomiting.

I am clueless right now. Any help or suggestions will be greatly appreciated!!!! Thanks!!!!!

It's acute pain r/t inflammation a/e/b patient rating pain on x on a scal of 0 to 10

Diarrhea isn't a n/d. Alteration in bowel pattern aeb watery frequent stool passage rt inflammatory process

Risk for deficient fluid volume r/t diarrhea

Risk for imbalanced nutrition less than body requirements r/t vomiting and diarrhea

Risk for hyperthermia r/t infectious process

Tweak as you like, or to correct. This is a quickie.

:)

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Specializes in med/surg, telemetry, IV therapy, mgmt.
Diarrhea isn't a n/d. Alteration in bowel pattern aeb watery frequent stool passage rt inflammatory process

Diarrhea has been an accepted nursing diagnosis in the NANDA taxonomy since 1975. It has researched related factors and defining characteristics.

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