if all her admitting symptoms were gone the doctor would have discharged her. when you care plan (determine a patient's nursing problems) the starting point is to do an assessment. assessment is step #1
of the nursing process:
step #2 determination of the patient's problem(s)/nursing diagnosis part 1
- a health history (review of systems)
- performing a physical exam - was there any cough? patient's who land in the hospital with chf have congested lungs. if her lung sounds were diminished, it means she still had congestion in her lungs, but was she coughing any sputum out?
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - look up chf which is a form of heart failure (left sided heart failure). you want to see if you missed seeing any of the signs and symptoms of it in her. also, you need to understand its pathophysiology in order to construct some of your nursing diagnostic statements. your understanding of the pain and edema in her lower legs might be explained by reading about heart failure and circulatory problems. did she have any other documented medical conditions?
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - is she on a drug for the heart failure that is constipating? is one of the side effects of the diuretics she is on constipation? has her eating pattern changed since being admitted? immobility also leads to constipation. is constipation a problem she has in life? this information needs to be known for the related factor of the nursing diagnosis.
- make a list of the abnormal assessment data that you have collected. this is what i was able to extract from the information you posted:
step #2 determination of the patient's problem(s)/nursing diagnosis part 2
- diminished breath sounds
- bp was 140/80
- urine output was 1600ml in about 7 hours - this is a result of the diuretics she is being given and indicates she still has a lot of fluid that needs to be diuresed.
- no bm's for 3 days
- pain rating 8/10 in her lower legs and feet (she attributed that to the swelling she had the last couple of days)
- match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
- ineffective airway clearance r/t retained secretions aeb diminished breath sounds
- decreased cardiac output r/t decreased contractility aeb elevated blood pressure and peripheral edema
- excess fluid volume r/t impaired sodium and water excretion aeb [symptoms of overhydration] peripheral edema
- constipation r/t diuretics and decreased physical activity (just guessing here) aeb no bowel movement for 3 days
- acute pain r/t tissue swelling aeb patient complaint of pain in lower legs of 8/10 on a scale of 0 to 10.
- - - - - - - - - - - - - - -
decreased cardiac output r/t impaired cardiac function amb ?? (i can't think of any manifestations that would fit this for her symptoms that day)
a diagnosis is chosen because of the symptoms a person has. if there were no symptoms, then it makes no sense to choose the diagnosis. acute pain r/t ?? amb pain rating 8/10 with numerical scale (i'm not sure what would be causing the pain... my instructor said that r/t previous edema in the lower extremities she isn't sure that was the cause) her pain was really the only syptoms i was treating that day.
investigate pain (look it up and read about the physiology of pain).she was on bed rest so i was thinking about activity intolerance.
what activity did she do? i didn't see any listed. activity intolerance is exactly what this diagnostic label says: insufficient physiological or psychological energy to endure or complete required or desired daily activities (page 134, nanda international nursing diagnoses: definitions and classifications 2009-2011).
diagnosis is based upon the symptoms (abnormal data) you collected when you assessed and observed the patient. this is no different from the way a doctor diagnoses. the difference is that we have the list of nanda diagnoses along with information that goes with them to help us in doing the diagnosing. every nursing diagnosis has a list of related factors (etiologies, causes) and defining characteristics (signs and symptoms) that nanda has already researched and put together for us. if you have a copy of taber's cyclopedic medical dictionary
you will find this taxonomy information in the appendix. about 80 of the most commonly used diagnoses have this taxonomy information online at these websites: