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
- 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?
- specific location of chest pain?
- how much sputum production?
- color of sputum?
- presence of crackles, wheezing or rhonchi?
- any diminished breath sounds? where?
- 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?
- systolic/diastolic murmurs?
- hematuria or dark urine?
- 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)
- cyanosis (in neonates only)
- decreased carbon dioxide
- diaphoresis (excessive sweating)
- headache upon awakening
- nasal flaring
- 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
- difficulty vocalizing
- diminished breath sounds
- excessive sputum
- ineffective cough
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
- the excess sputum he's coughing up
- 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.