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 :
Chronic pain possibly r/t inflammation of intestines aeb pt states "my stomach hurts right here" pointing to lower left abdomin.
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?)
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!!!!!
SuesquatchRN, BSN, RN
10,263 Posts
Cool. We're still using alteration at work.