nursing diagnosis help!

  1. 0
    I need some help with my diagnoses:
    Case study
    I have a 80 yr female pt who admitted to ED complaning of 'not feeling well' and 'out of breath'. She had minor physical trauma (cut and abrasions) before the complaints.


    Medical history:
    - three previous heart attacks
    - has congestive cardiac heart failure

    Signs:
    - HR 130 BPM, irregular (tachycardia & arrhythmia)
    - BP 90/50 (low BP)
    - RR 26 BPM (tachypnoea?)
    - SaO2 89% on air (low sat, possibly hypoxemia)
    - temp 36.7 (normal)

    Symptoms
    - pt complaints (listed above)
    - shortness of breath
    - visible use of accessory muscles
    - appears to be agitated
    - requires frequent repetition of questions (decreased LOC? confusion? changes in mentation?)

    Roles-relationships pattern
    - normal except she has been a widow for 2 yrs



    Based on case information I wrote:

    Decreased cardiac output related to congestive cardiac heart failure (CCHF) and previous history of heart attacks (HF) as manifested by rapid heart rate, irregular heart rhythm , decreased LOC (or changes in mentation or confusion), advanced age, tachypnoea and low BP.

    Ineffective breathing pattern related to decreased cardiac output and possible anxiety as manifested by use of accessory muscles, rapid respiratory rate and low SaO2.

    Ineffective cardiopulmonary tissue perfusion related to decreased cardiac output as manifested by low oxygen saturation, rapid heart rate, irregular heart rhythm, shortness of breath, and visible use of accessory muscles, changes in mentation.

    Impaired gas exchange
    related to ventilation-perfusion imbalance (or imbalance between oxygen supply and demand) as manifested by dyspnoea, confusion, tachycardia and arrhythmia.
    Risk for activity intolerance related to decreased cardiac out.


    Assigning priorities:
    1. decreased cardiac output
    2. ineffective breathing pattern
    3. impaired gas exchange
    4. ineffective cardiopulmonary tissue perfusion
    5. risk for activity intolerance


    Thank you
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  3. 8 Comments so far...

  4. 0
    I think you're off to a good start, but how about some physical exam data related to cardiac output and perfusion? You listed vital signs and an assessment of work of breathing, but what are some good physical exam findings to assess when you have a cardiac patient that may be poorly perfused?
  5. 0
    All physical exam findings given in this case are listed above...there is no more.

    I have to write 'assessment' part which asks me to list two asessment tool to assess this patient. So far, I think I need a complete health history (including lifestlye -diet & level of physical activity; symptoms recognition etc) as well as ECG. I found some peer-review journal articles that ECG should be performed in all patients with arrhythmia.

    But based on Maslow’s hierarchy, should I prioritise ineffective breathing pattern first? but I think decreased cardiac output has contributed to ineffective breathing pattern.

    thank you for your response really helpful
  6. 1
    Ah, sorry. Didn't read carefully enough to realize that this was a case study. I hate those things.
    psu_213 likes this.
  7. 0
    Airway and breathing are always a higher priority than circulation. Also..you cannot use medical disgnosis as your -related to - in your ND
    1.gas exchange
    2. Breathing pattern
  8. 0
    Quote from 2013SNGrad
    Airway and breathing are always a higher priority than circulation. Also..you cannot use medical disgnosis as your -related to - in your ND
    1.gas exchange
    2. Breathing pattern
    Not true. Many nursing diagnoses in the NANDA-I 2012-2014 have medical diagnosis as a related factor (cause).
  9. 0
    We were always taught to use medical diagnosis as a 2° not r/t.
    We were taught to explain pathophysiology as related to...just saying
  10. 1
    Quote from ryody001
    I need some help with my diagnoses:
    Case study
    I have a 80 yr female pt who admitted to ED complaning of 'not feeling well' and 'out of breath'. She had minor physical trauma (cut and abrasions) before the complaints.

    Medical history:
    - three previous heart attacks
    - has congestive cardiac heart failure

    Signs:
    - HR 130 BPM, irregular (tachycardia & arrhythmia)
    - BP 90/50 (low BP)
    - RR 26 BPM (tachypnoea?)
    - SaO2 89% on air (low sat, possibly hypoxemia)
    - temp 36.7 (normal)

    Symptoms
    - pt complaints (listed above)
    - shortness of breath
    - visible use of accessory muscles
    - appears to be agitated
    - requires frequent repetition of questions (decreased LOC? confusion? changes in mentation?)

    Roles-relationships pattern
    - normal except she has been a widow for 2 yrs



    Based on case information I wrote:

    Decreased cardiac output related to congestive cardiac heart failure (CCHF) and previous history of heart attacks (HF) as manifested by rapid heart rate, irregular heart rhythm , decreased LOC (or changes in mentation or confusion), advanced age, tachypnoea and low BP.

    Ineffective breathing pattern related to decreased cardiac output and possible anxiety as manifested by use of accessory muscles, rapid respiratory rate and low SaO2.

    Ineffective cardiopulmonary tissue perfusion related to decreased cardiac output as manifested by low oxygen saturation, rapid heart rate, irregular heart rhythm, shortness of breath, and visible use of accessory muscles, changes in mentation.

    Impaired gas exchange related to ventilation-perfusion imbalance (or imbalance between oxygen supply and demand) as manifested by dyspnoea, confusion, tachycardia and arrhythmia.
    Risk for activity intolerance related to decreased cardiac out.

    Assigning priorities:
    1. decreased cardiac output
    2. ineffective breathing pattern
    3. impaired gas exchange
    4. ineffective cardiopulmonary tissue perfusion
    5. risk for activity intolerance

    Thank you
    Minor point- you have advanced age listed as a manifestation of decreased CO.... I'm gonna' go with not-so-much. I'm sure you know that.
    psu_213 likes this.
  11. 0
    Quote from 2013SNGrad
    We were always taught to use medical diagnosis as a 2° not r/t.
    We were taught to explain pathophysiology as related to...just saying

    How about a patient who has, oh, (random page flip here) the nursing diagnosis of Nausea? A large number of the "related to" factors (which are causative) are medical diagnoses, not nursing observations (those are the "defining characteristics"). Look on page 476 of your NANDA-I 2012-2014, which is the authoritative reference on what is and is not a nursing diagnosis and how to make it, and you'll see what I mean. Just saying.

    What they don't want you to do is say, "My patient has uremia. Therefore he has the nursing diagnosis of nausea." No...he might have nausea there for you to assess, and you must do that before you can make the nursing diagnosis. Maybe he doesn't. Maybe he's uremic as all get-out but is not nauseated. That's why you assess him yourself before making the diagnosis.

    That's why they say you don't relate it to the medical diagnosis. But trust me: If NANDA-I says you can use a medical diagnosis for a nursing diagnosis and lists it in the related factors for the nursing diagnosis, you can use it.

    "Due to" and "Secondary to" and "Related to" all mean the same thing.


    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ .
    I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________. He has this because he has ___(related factor(s))__."


    "Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."


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