Is this a valid nursing diagnosis?

  1. I am supposed to provide 3 nursing diagnoses for a pt w/ angina pectoris.

    1- pain r/t myocardial ischemia
    2-Risk for decreased cardiac output r/t mechanical and/or electrical dysfunction of the heart
    3-Anxiety r/t angina aeb pt stating " Every time that I get angina, it makes me nervous that I will have a heart attack"

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  3. by   rachelgeorgina
    valid, but you're missing the "as evidenced by" for 1 and 2. what signs and symptoms is the pt exhibiting to lead you to your diagnosis?
  4. by   Daytonite
    you say that the patient's medical diagnosis is angina pectoris. so, we need to start from there and understand the underlying pathophysiology of what is going on with that in order to properly format your nursing diagnostic statements. angina pectoris occurs when there is coronary artery disease (cad). cad is atherosclerosis of the coronary arteries which causes their narrowing that results in an inadequate blood supply to the heart itself. it often takes years to occur and chest pain, specifically, angina pectoris (ischemia) is a symptom of it and eventually heart damage and heart attack happens. the symptoms of cad include (in order of appearance):
    • angina that may radiate to the arm, neck, jaw or shoulder after physical activity, emotional stimulation, ingestion of a large meal, exposure to the cold or while asleep
    • nausea, vomiting
    • fainting
    • sweating
    • increased episodes of angina that occur with more frequency and duration and can be brought on more easily (indicative of the worsening of the disease process)
    • cool extremities
    • xanthoma (yellow plaque or nodule on the eyelids near the inner canthus)
    • arteriovenous nicking of the eye
    • hypertension
    • positive levine sign (holding the fist to the chest)
    • decreased and absent peripheral pulses
    here is information about these conditions:
    diagnosis is always based upon the signs and symptoms that the patient has. the only evidence that you have provided that i can work with is that this patient has angina pectoris which i know means that they have some degree of cad except i do not know what other physical evidence they have of it. i worked on a cardiac unit early in my nursing career where we had a lot of patients who would get chest pain. along with their chest pain they usually got anxious, blood pressure changes, dyspnea and tachycardia. i made up an assessment sheet for myself to watch for all these signs and symptoms because i used to sit at their bedside as i gave them nitroglycerin tablets, took their vital signs and listened to their hearts and lungs so i wouldn't forget anything i needed for my documentation. (i still have the sheet and i am looking at it now.) you did list with one of your diagnostic statements "every time that i get angina, it makes me nervous that i will have a heart attack" which tells me that this episode of chest pain is not the first one and that it has occurred before. someone has told the patient that the angina is a forerunner of what may happen--a heart attack--so they do know something about what is going on. my next question is do they have any of the risk factors?
    • family history of heart disease or relatives that have died of a heart attack
    • high cholesterol level
    • history of, or do they smoke
    • diabetes
    • use of hormones
    • obesity
    • sedentary lifestyle
    • stress
    • elevated homocystine levels
    now, lets look at your nursing diagnoses. . .first i need to re-sequence them.

    • risk for decreased cardiac output r/t mechanical and/or electrical dysfunction of the heart
      • this is actually not a risk anymore. the decreased cardiac output is here and it is here to stay. this person's heart is damaged by the effects of cad which is a chronic disease and it is going to get worse as time marches on. this patient will eventually need ptca or cardiac bypass or they will end up having a heart attack. the angina pectoris is a symptom of the cad that they have. the doctor just didn't tell you about the cad. when you see angina pectoris you should automatically connect it with cad.
      • the related factor (cause, reason) for the decreased cardiac output [we're getting into the pathophysiology here] is that the heart tissue itself isn't getting enough oxygen. electrical dysfunction is a result of that and other mechanisms going on.
      • symptoms of angina that are also symptoms of decreased cardiac output are tachycardia, palpitations, dyspnea, change (usually a rise) in blood pressure and, of course, this patients anxiety.
      • your diagnosis should read something like this: decreased cardiac output r/t myocardial ischemia aeb [need to verify that these were present: tachycardia, palpitations, dyspnea, elevated blood pressure and anxiety]
    • pain r/t myocardial ischemia
      • the correct nanda diagnosis is acute pain.
      • your related factor is correct.
      • it is important to assess pain so that it is measurable:
        • assessment and description of pain includes the following:
          • where the pain is located
          • how long it lasts
          • how often it occurs
          • a description of it (sharp, dull, stabbing, aching, burning, throbbing)
            • have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
          • what triggers the pain
          • what relieves the pain
          • observe their physical responses
            • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
            • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
            • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
      • your diagnosis should read something like this: acute pain r/t myocardial ischemia aeb [pain of __ out of 10 on scale of 0 to 10]
    • anxiety r/t angina aeb pt stating "every time that i get angina, it makes me nervous that i will have a heart attack"
      • anxiety is apprehension, dread, fear or threat of the unknown. the related factors of the diagnostic statements must always attempt to explain how or why the problem exists as close to the cause as possible. although anxiety has a lot of physical symptoms it is primarily one of the psychosocial diagnoses. look at your evidence supporting it: every time that i get angina, it makes me nervous that i will have a heart attack. that translates, to me, that the patient is afraid of something and that the chest pain represents a threat to their life or health. now, you interacted with this patient, so you know what was said between you. there is another nursing diagnosis called death anxiety where patients are in fear of dying. if it is appropriate, use that diagnosis. otherwise, this should be re-written as anxiety r/t threat to health aeb patient's statement that "every time i get angina, it makes me nervous that i will have a heart attack."
    to recap, in priority order (by maslow's hierarchy of needs) the 3 diagnoses are:
    1. decreased cardiac output r/t myocardial ischemia aeb [need to verify that these were present: tachycardia, palpitations, dyspnea, elevated blood pressure and anxiety]
    2. acute pain r/t myocardial ischemia aeb [pain of __ out of 10 on scale of 0 to 10]
    3. anxiety r/t threat to health aeb patient's statement that "every time i get angina, it makes me nervous that i will have a heart attack."
  5. by   Student4Now
    Thank you! I don't know what was going through my head when I put risk for decreased cardiac output, because the pt already has decreased cardiac output. Such a simple mistake on that one, but had you not brought it to my attention, it would have stayed there...The question was quite vague as it only asked "what are 3 nursing diagnoses for a pt w/ angina pectoris." I think that we are supposed to fill in the blanks, which lead me to anxiety and the pt statement.
  6. by   Daytonite
    When you are given these exercises to do and all they give you is a medical diagnosis, the first thing you have to do is break the medical diagnosis down into its component signs and symptoms and look up the pathophysiology. The signs and symptoms are the manifestations of the pathophysiology and will become the AEBs for the nursing diagnoses. The pathophysiology gives you the reasoning for the related factors on the nursing diagnoses that you end up using. I did not know this was a hypothetical patient. I was just responding to your question. Otherwise, based on the patient statement I would have suggested using Deficient Knowledge, CAD R/T lack of information AEB patient need for information about disease and how it progresses.
  7. by   Student4Now
    Decreased Cardiac Output r/t myocardial ischemia AEB ?????

    I know the pt has decreased cardiac output b/c he has myocardial ischemia, but the assignment didn't give signs and symptoms so would I just assume that the pt is experiencing things typical to this certain disease?

    Deficient Knowledge, CAD R/T lack of information AEB patient need for information about disease and how it progresses.
    I totally understand this one, b/c every pt needs info on their disease.

    Acute Pain r/t myocardial ischemia AEB ??? Once again shld I just use something general such as "AEB diaphoresis, nausea, Levine's sign"?

    *Altered tissue perfusion(myocardial) r/t narrowing of the coronary arteries and associated with artherosclerosis, spasm, or thrombosis

    * taken from Diseases and Disorders
    Last edit by Student4Now on Jun 30, '09 : Reason: left out a word :P
  8. by   Daytonite
    decreased cardiac output r/t myocardial ischemia aeb chest pain.

    i know the pt has decreased cardiac output b/c he has myocardial ischemia, but the assignment didn't give signs and symptoms so would i just assume that the pt is experiencing things typical to this certain disease?
    i didn't know this was a scenario for a hypothetical patient. i will sometimes give a list of symptoms to refresh student's minds in hopes that they may have seen one or more of them in the patient and just forgotten to write them down. if this was a scenario then all the signs and symptoms they wanted you to be aware of were given to you. still, it doesn't hurt to know what a textbook has to say.
    acute pain r/t myocardial ischemia aeb chest pain. once again shld i just use something general such as "aeb diaphoresis, nausea, levine's sign"?
    angina pectoris is a medical diagnosis. in nursing language it is chest pain. the other stuff is from a textbook.
    *altered tissue perfusion(myocardial) r/t narrowing of the coronary arteries and associated with artherosclerosis, spasm, or thrombosis
    yes, you could use this diagnosis, but. . .coronary spasm would be manifested by continued severe chest pain and that is not what is going on here. coronary thrombosis is an mi and that is not what is going on here either. read the pathophysiology of cad along with its symptoms. match the patient's symptoms (chest pain) to where he is in the chain of atherosclerosis to mi. he's obviously got some narrowing of the coronary arteries going on, but the degree of it will be unknown without further testing. if his chest pain happens now and again with activity his cad isn't as bad as someone coming in grabbing at their chest claiming they are having crushing chest pain, sweating and complaining of the worst indigestion of their life (symptoms of an mi).
  9. by   DolceVita
    Daytonite -- when do you get a rest!
  10. by   Daytonite
    Ha! Ha! In between the posts I was actually over at the local hospital getting some x-rays and I have been sitting here looking at sweater patterns (I knit and crochet when I am bored) and watching Episode 1 of Star Wars on Spike. I kind of know this stuff, or at least where to look it up in my books around here. I used to work on a medical cardiac unit.
  11. by   Student4Now
    There wasn't a scenario. It just asked us to come up with 3 nursing diagnoses for a pt with angina pectoris. Which I thought was kind of weird b/c they gave us no pt. specifics.
  12. by   Daytonite
    well it is practice for when you get the real deal. i have been sitting over here for over a year trying to figure out an easy way to explain to everyone "how to diagnose". i have a number of care plan books and not one of them really addresses the subject. they sort of skim over it by saying "and then you pick the nursing diagnosis". right. but they don't say how you actually do that. i have gone to medical school websites and talked to my two bils who are docs as well as tried to pull this "secret" (it seems) information out of my oncologist who is a very chatty fellow and i can't get the low down. it is a difficult concept to convey to someone. i understand it, but it is difficult to explain it to someone who seems to have that deer in the headlights look. it is just a difficult concept to break down into something i can make understandable.

    actually, if you have your own recent copy of taber's cyclopedic medical dictionary you will find a nursing diagnosis to medical disease cross reference in the appendix. however, it won't help you if you get a patient or you are given a medical diagnosis that isn't included in there.
  13. by   Student4Now
    I am working forward in the program ( have all the assignments) but not actually back in the program yet. I guess that is a mute point though because they don't "teach" or lecture at all. I do understand the basic concept of the nursing diagnosis ( I think) but I still have SO MUCH to learn, and so many new concepts to grasp. I am having a hard time coming up with these particular diagnoses because they are so vague. I wish they would have given a little more info about the pt. But I guess one thing about being a nurse is learning to work with what you have. I know the pt has angina pectoris, which means they are having acute pain, have decreased cardiac output, and altered tissue perfusion all r/t myocardial ischemia. I think those are my 3 best bets, although I am still having a hard time with the AEB's due to the fact that I dont have any patient info or real "evidence." LOL Its a vicious circle!!!! I will def. check out the Dictionary you suggested, as I think it will be a great source of info and I will be able to see a lot of examples there. Thanks so much for your time, I really do appreciate it, I have learned a great deal more from reading your posts than I ever learned from the advisors when I was in the program.
  14. by   Daytonite
    what you have to start doing is when you are told someone has a condition like angina pectoris (but understand that it can be any disease or condition) is to start asking yourself "what is actually going on here?" and "why" is this chest pain happening?" when i was first in nursing school years ago we didn't have any formal lectures and were told to find information on our own. one of the things we were constantly guided to do was to ask ourselves and find the answer to "why" things were happening. that, i later learned, is one of the crucial components of critical thinking although i didn't understand it at the time. because, you see, these things (like chest pain or angina pectoris) don't just show up for unknown reasons. there is a rationale for everything that happens and everything that both the doctors and we are going to do for that patient. that is the critical thinking part in all this. get that and you've learned what you needed to about it.

    chest pain is one of the most common reasons that people are seen in the er. that is all they come in complaining of and many times that is all you will know about them at first. but by exploring the symptom of chest pain and the diagnosis of angina pectoris you can learn so much. there are other things to look for and ask about when these patients come in which is why we must do an assessment. assessment is critical to the determination of their problems. assessment for us nurses consists of:
    • a health history (review of systems)
    • performing a physical exam
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
    the nursing process in the simplest definition is the method we use to solve problems. it has 5 steps. specific activity goes on in each step.

    1. assessment
    2. problem determination
    3. planning
    4. implementation
    5. evaluation
    the nursing process comes from the scientific process and it is not used exclusively by us nurses. many other professions and disciplines use it, or some form of it, to solve questions they have. we actually use this rational process outside of nursing to solve problems. it's just that we never sat down and broke it into its component parts. a nursing diagnosis is a concept that came about while i was in nursing school years ago. it comes under step 2 of the nursing process, problem determination. the nursing diagnosis itself is merely a label, it is a tag like you would place on a cupboard or a drawer, associated with one or more signs and symptoms that refer to a certain nursing problem. every nursing diagnosis has a definition and that is what you really want to look at. these definitions are in the nanda taxonomy (such as the appendix of taber's cyclopedic medical dictionary or it can be purchased from nanda). that is one of the reasons nanda came about--to organize and standardize the diagnostic information so everyone would know what we were talking about when we used each diagnosis. otherwise, there would be a lot of confusion and who would know what a diagnosis meant if it wasn't clearly defined? before nanda we merely listed signs and symptoms as the patient problems on care plans. someone began to figure out that some of the signs and symptoms could be grouped together and nursing diagnoses were born. however, the remainder the care planning process (problem solving) didn't change. once the problem is identified we still need to do something about it. and that is step 3 and 4 of the nursing process. now, this is an analogy that i sometimes post that gives you an example of how the nursing process works in the real world:
    you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).
    there is nothing random about the way we do things. you just need to learn how to think like a nurse.

    nursing diagnoses are based upon a patient's response to what is happening to them. that is very different from how medical diagnoses are set up. just look at a taxonomy page for one diagnosis as a time and read the definition, related factors and defining characteristics. as you do, you will begin to see how they fit together. read some of the information that is there on the diagnostic pages of the care plan constructors.

    eventually, you will begin to see the thinking process going on.

    decreased cardiac output is one of the more difficult nursing diagnoses to understand. it is one of the physiological ones. it is often confused with ineffective tissue perfusion especially when issues of ischemia (oxygen deprivation to the tissues) come up. decreased cardiac output takes in all problems of malfunctioning of the heart both electrical and mechanical and includes ischemia of the heart. this year nanda has done away with ineffective tissue perfusion, cardiopulmonary which i thought was only used for pulmonary emboli anyway and i would suggest that nurses diagnose according to the response and symptoms the patients exhibit as a result of the perfusion problem.