8 nursing diagnosis for pt with Sickle Cell/ Pneumonia

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    Hey all. Im having trouble coming up with 8 Diagnosis for my patient. He hasnt had too much past medical problems and is 46. He does have hypertension, and DVT however. Anyhow I know of course the first diagnosis will be acute pain r/t sickle cell crisis. Im not sure where DVT would come in though as far as diagnosis. Impaired mobility, activity intolerance, risk for constipation r/t morphine, dilaudid. other than that I dont really know. My teacher gave me all ogod marks on my past careplans but insists i need a lot of work in my diagnosis section and I agree. This is my 1st time working with a sickle cell patient however so it will be a learning experience. The only thing i do not understand however is that I am on a cancer floor, so im confused why this patient would be here. And from my research I understand that sickle cell pain comes and goes, and also ahs no cure. So I dont understand really all the hospital day entails, besides narcotics and rest. Im not sure what else I can include in my care, besides controlling pain and patient teaching.
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    I do know that penumonia is very significant and of course the diagnosis would be related to it. However Im not sure that anything would knock off the acute sickle cell pain from the number one spot. followed by perhaps ineffective breathing pattern?? however I have no proof of this,because his rep rate was charted ~15-17 over the last 4 days. but does the fact that he has pneumonia allow you to assume ineffective breathing?
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    Ineffective airway clearance, Ineffective tissue perfusion, activity intolerance...?
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    first of all, sickle cell anemia is considered a disease of the hematologic system. so, is leukemia which is a cancer. sickle cell patients are sometimes placed on the same units where leukemia patients are assigned because of the similarities of some of their symptoms. the patient's major underlying condition is their sickle cell anemia. the hypertension, dvt and pneumonia may be complications of their sickle cell disease. the very first thing you need to be doing is looking up information about the disease of sickle cell anemia and it's pathophysiology. under information about sickle cell crisis you will find out some reasons why the patient's dvt may be related to his sickle cell crisis. you need to understand what is happening during a sickle cell crisis that leads to the formation of blood clots in the patient's circulatory system and how those microclots are causing the pain they are having.

    once you do that as well as look up information on hypertension, pneumonia and dvts, then make a list of all the symptoms you found from going through the medical record of this patient as well as your physical assessment. you will see that some of those symptoms are going to be directly related to the sickle cell crisis going on. other symptoms will be of their own etiology. only then, can you start to pick your nursing diagnoses.

    we've been through this whole care plan process before. i went back and i checked your past threads. i helped you with three other care plans but you never have come back looking for more specific information on nursing diagnoses once you had nursing diagnosis titles. determining the nursing diagnosis title is not enough. there are other elements that go into writing the nursing diagnostic statement. they involve putting together the assessment information you have collected and understanding the pathophysiology of the medical disease and the definition of the nursing diagnosis you are using. there are 3 parts to a nursing diagnosis statement. the title is only one element.

    to review the previous information i've given you, here are links to them:
    i want to help you, but you are not giving me enough imformation.
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    Yes, Thank you for your help as always daytonite. I do know there is more to it than the diagnoses titles. We have to come with 8, and work out the top 3 priorities including a goal and outcome with 5 interventions for that goal and outcome. The links you provde me are always very helpful. My teacher says i need to work on, ordering my diagnosis better. The diagnoses I come up with after your help has always been correct, but when i get down to the 3rd or 4th diagnosis, i apparently order them incorrectly. Which she says will come with time. but a lot of it is like you said reviewing the disease processes and pathology and the symptoms associated with them. But somehow I just have a problem making diagnoses titles. Once I have the titles I am good at researching and using my careplan books to set goals outcomes and rationales. The only problem with careplan books is that they give you a VERY GENERAL idea, and of course my goal to be a good nurse includes to make each care plan specific to my patient. a,b,c's airway is an issue obviously as my patient is on albuterol prn. so would that be ineffective airway clearance, i spoke wiht him this afternoon when i was checking otu this chart, he seemed pretty cheerful and alert and said he was in level 7 pain and his chest just kills him. He has been doin the incentive spirometer, his resp rates have been normal over the last few days. Circulation.... he has a high bp... he is a smoker and drinks alcohol regularly. I have researched sickle cell and I do know that it correlates with his dvt. He is on lovenox... what kind of diagnosis could i make in regards to dvt? he told me he has a sore throat, a little bit of a headache, and cough with sputum. I know he is going to have activity tolerance because first of all he is on disability from it already, and the man is in pain. I am having a hard time to learn about sickle cell however, seems there is no cure, and there is not much you can do besides manage the pain with opiods until the acute phase passes. But im sure i have a lot to learn about dvt. He has no wife/gf or kids. He does have a sister in jacksonville who came and visited him a few times. He did check him self in. no histories of recent surgery in his charts. his weight has not changed, he is probably fatigued. He did throw up 2 times before today, but his weight has not changed and they have him as eating most of his meals and he is on regular diet.
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    first of all, you need to stop associating nursing diagnoses with medical diagnoses. they are not the same thing. when a doctor goes about determining a patient's medical diagnosis he/she assesses the patient and takes their symptoms into consideration; when a nurse goes about determining a patient's nursing diagnosis he/she assesses the patient and takes their symptoms into consideration.

    what i'm saying is the information you collect about your patient during the assessment is critical to determining what the nursing diagnoses are going to be. now, from your third post i was able to pull out these symptoms that you finally mentioned:
    • chest pain, 7 on a scale of 10
    • headache [are the chest and head the only places he has pain?]
    • sore throat
    • elevated blood pressure [how high? what was his actual b/p?]
    • cough productive of sputum
    • activity intolerance [this needs to be stated in more specific terms, such as, unable to walk, unable to turn, can only walk 10 steps before becoming fatigued and having to sit down]
    you mentioned he was "probably fatigued". that was only a guess on your part, correct? not really an observation you made, correct? assessment data has to be real, not a guess.

    with pneumonia, sickle cell crisis and a dvt, i'm betting that there's a few assessment items you missed. so, look at the following list and see if there's something you forgot to include. if so, you need to add it now to that list i just stated above.
    • what was the assessment of his leg with the dvt like?
      • any tenderness, pain or aching?
      • any fever or chills?
      • any redness or swelling of the leg?
      • was the leg measured?
      • positive or negative homan's sign?
      • patient statement that the leg felt warmer than the other leg?
    • what was the pneumonia/lung assessment?
      • fever?
      • specific location of chest pain?
      • how much sputum production?
      • color of sputum?
      • presence of crackles, wheezing or rhonchi?
      • any diminished breath sounds? where?
      • tachypnea?
      • use of accessory muscles to breath?
      • oxygen in use?
      • pallor or cyanosis?
    • with relation to the sickle cell disease/crisis:
      • any jaundice or pallor? pale lips, tongue, palms or nail beds?
      • tachycardia?
      • dyspnea?
      • systolic/diastolic murmurs?
      • sleepiness?
      • hematuria or dark urine?
      • fever?
      • complaints of severe abdominal, thoracic, muscle or bone pain?
    the reason it's important to have this list of your patient's symptoms is because these are the things that are going to get treated. the doctor will write some orders for things that the nurses will carry out. nurses will be able to do some interventions for some of these symptoms without needing a doctor's order. however, everything that you will do for this patient is going to be aimed at the things that are on that list of symptoms. you do not, in any way shape or form, ever treat the medical disease. so, if there's something being done for the patient and the reason (symptom) for it is missing from the symptom list, you gotta find that missing symptom and figure out where you went wrong in missing it. it is ok to get some of this information from the medical record (doctor's history and physical, er record, other nurse's notes, physical therapy notes, etc.). http://allnurses.com/forums/f205/hel...ay-227507.html

    to get nursing diagnoses, you have to look at a nursing diagnosis reference to see which of these symptoms show up under likely nursing diagnoses that you are going to be able to use. now, you can use the medical diagnosis information to help you out a little bit, but only to help give you some short cuts to picking out potential nursing diagnoses. you still have to check to see if your patient's symptoms are going to confirm that your patient's symptoms go with those diagnoses.

    for example, with pneumonia, possible diagnoses to look at are:
    • impaired gas exchange
    • ineffective airway clearance
    • impaired oral mucous membranes
    • risk for deficient fluid volume
    looking at the nursing diagnosis of impaired gas exchange i see the following symptoms listed (they are actually called defining characteristics by nanda) [page 94, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international]:
    • abnormal arterial blood gases
    • abnormal arterial ph
    • abnormal breathing (rate, rhythm, depth)
    • abnormal skin color (pale, dusky)
    • confusion
    • cyanosis (in neonates only)
    • decreased carbon dioxide
    • diaphoresis (excessive sweating)
    • dyspnea
    • headache upon awakening
    • hypercapnia
    • hypercarbia
    • hypoxemia
    • hypoxia
    • irritability
    • nasal flaring
    • restlessness
    • somnolence
    • tachycardia
    • visual disturbances
    your patient doesn't have any of those symptoms (unless you failed to notice them), so you can't use this nursing diagnosis.

    let's look at the symptoms (defining characteristics) for ineffective airway clearance [page 5, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international]:
    • absent cough
    • adventitious breath sounds (this would be rales, rhonchi or wheezes)
    • changes in respiratory rate
    • changes in respiratory rhythm
    • cyanosis
    • difficulty vocalizing
    • diminished breath sounds
    • excessive sputum
    • ineffective cough
    • orthopnea
    • restlessness
    • wide-eyed
    your patient has a cough that is productive of sputum, but is he having trouble clearing it from his airway? this nursing diagnosis is specifically defined as "inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway".

    do you see where i am going with your assessment data and how important it is? let's say this patient is constantly bringing up rust colored sputum and has wheezes through his lung fields. then, you could say he has:
    ineffective airway clearance r/t excessive mucous production aeb excessive sputum production and the presence of wheezes throughout all lung fields.
    your nursing goals and interventions will be focused on
    1. the excess sputum he's coughing up
    2. the wheezes
    i didn't play around with the acute pain nursing diagnosis because i think it is going to be a bit more complicated. this patient has pain in a number of different areas. you need to sort out exactly where these areas of pain are and how intense the pain is as well as the etiology of each of the different pains. for instance, the sore throat is going to be from the irritation of coughing. the pain in the chest either from coughing or it might be from a microclot due to the sickle cell crisis. if he has pain in the leg it might be from the clot or from the pressure of the swelling being exerted on the tissues. this is all information that you have determine before writing the nursing diagnosis. your nursing diagnostic statement may end up being a compounded one with several r/t reasons as well as at least 3 aebs symptoms.

    that should get you started. i'm having problems staying online, but as soon as i can get a good connection i'll try and get you some informational weblinks on some of these medical conditions for you to read.
  9. 0
    thanks for the noter


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