Quote from scrubaway010
I'm really lost in prioritizing the nursing diagnosis for the following patient.
He is 41yrs
admitting dx chest pain rule out MI
his bp 118/68, RR- 18 bpm
chest pain since 3 days
Pt states: "my chest hurts", "I feel I can't breathe properly", facial grimaces.
since 2/3 months 10 people live with him; "don't like lot of people", likes to be left alone.
No Past medical history.
Troponin values are normal
BUN/Creat ratio is low
Meds: morphine sulphate 2mg/IV Q2PRN pain
nitroglycerine 0.4mg/SL PRN for chest pain
ondansetron 4mg/IV Q6H PRN
Zolpidem Tartrate 5mg/PO
For my first nursing diagnosis, can I write:
Ineffective breathing pattern r/t pain AEB facial grimaces, pain 7/10, and patient states, "my chest hurts"
Patient will maintain regular breathing pattern AEB pain 2/10 scale by the end of shift.
For my second:
Can I use activity intolerance?
I'm not sure if I'm prioritizing right. I kind of feel lost, could anyone please tell me what I'm doing wrong and if my selection of diagnosis is right?
Thanks a lot!
This is the important part of developing a nursing diagnosis: What was your assessment? This is what you have listed
Subjective: "my chest hurts", pain 7/10, "I fell I cannot breath properly", chest pain for three days
Objective: Facial Grimices, No PMHX, Admission Chest Pain R/O MI, VS: 118/68, RR: 18 (No Pulse or Pulse ox?), Troponin: Normal
What was your physical assessment? You can also obtain information to support your nursing diagnosis. You need data to support your choice of diagnosis since this is essentially your proof of your choices. Now from what you have written in priority of diagnosis:
Acute pain r/t (need more information to determine this)
To support impaired breathing or impaired oxygen you need information regarding Lungs (Clear???), Oxygen sat???,
Knowledge deficit: you need to substantiate this with more information.
Activity Tolerance: What information here can show proof of this???? You do not define what activity he can or cannot perform. Does he have problems with ADLS????
He does not like to be around people and likes to be alone? In affect this may have to deal with coping, but again not enough information to determine if this is his usual pattern.
Therefore you need to have more data to determine your priority nursing diagnosis. Pain can be proven, however the related factors need more information. This patient has normal labs, yet no pulse is written so could it be decreased cardiac output??? impaired tissue perfusion-cardiac???, anxiety (mild), etc. Also as to SOB, could this be due to anxiety??? which is causing the pain to chest??? You are missing vital information, if you had a head to toe assessment and highlighting your abnormals, you will then have the data to be able to formulate the nursing diagnosis for this patient.
Hope this helps. :typing