Nursing diagnosis help

[Stoogesfan]

My client had diabetes mellitus and his morning accucheck was 172. For breakfast he had a sausage, egg and potatoes bowl, orange juice and a cinnamon roll.

So for my nursing diagnosis I was thinking either ineffective self health management or risk for unstable glucose level.

I was considering possibly knowledge deficit but he told me that he didn't think orange juice was ok to have but since it was on the menu he figured they (the hospital cafeteria) knew what he could and couldn't have.

What does anyone think of those?

[MendedHeart]

A troponin of 0.1 is elevated. I think I would not rule out ACS. Coronary perfusion would be a good place to start, maybe reason for SOB and CP:)

[Esme12, ASN, BSN, RN]

He had no skin issues, no immobility, no pain, no shortness of breath, no apparent depression or anxiety that I observed and he never gave any indication that he was having social issues, his wife was at his bedside the whole time, he was alert and oriented, his lungs were clear, bowel sounds were normal, no diarrhea, constipation, no voiding issues. He did say he had pneumonia about 3 months ago but X-rays were clear and he wasn't taking any antibiotics. No cough.

I ended up talking to my instructor and she agreed to let me do a risk for diagnosis. He was on diuretics, two anytihypertensives and an antidepressant so I chose risk for falls.

If he is on

diuretics, two anytihypertensives and an antidepressant

You think the risk of falls is the most important diagnosis for a diabetic patient having chest pain.....what is the normal for a troponin at the facility where this patient is admitted...many do not feel this is a "normal" troponin. Is this a troponin I or tropinin T. from your post I am going to guess troponin I. I have seen more commonly...negative values are

[Stoogesfan]

It was troponin T and the normal per facility was 0 to 0.2. Troponin I didn't have a level. I asked my instructor about the level for that and she said that if it wasn't given than it wasn't ordered for some reason. She honestly acted like I was an idiot for even asking.

There is a risk of electrolyte imbalance with diuretics. I'll have to think about some more. I'm on lunch break at clinicals right now and it's time to go back to the floor.

Thanks for all your help :)

[MattNurse, MSN, RN]

That blood sugar for a diabetic non-fasting is rather normal and probably won't lead to much pathology. I would go with something related to his chest pain/SOB as the nursing diagnosis, all the other issues are chronic issues that you wouldn't address much in an acute care telemetry unit. If his A1C or diabetes was way out of control or he didn't know how to self administer his insulin then I would use knowledge def. Also you didn't mention if the patient had several troponins measured at that point, often the second or third troponin is elevated. If a patient comes in for chest pain we don't leave them in that state, often they get relief in the ED with oxygen, morphine, aspirin and nitro. But our focus still remains through our care plan the main issue that they come in with, we continue to intervene.

I would do something like this:

Acute pain may be related to tissue ischemia (coronary artery occlusion) evidenced by reports of chest pain with or without radiation.

TPW verbalize relief/control of chest pain within appropriate time frame for administered medications. TPW display reduced tension, relaxed manner, ease of movement.

you could also do something like activity intolerance, risk for decreased cardiac output, ineffective tissue perfusion etc.

If that patient is on a diabetic diet at the hospital you are correct that the meal he was provided is balanced, usually the insulin will take into account the carbohydrates in the sliding scale. If he is not on a diabetic diet just clarify and change the order.

[Esme12, ASN, BSN, RN]

It was troponin T and the normal per facility was 0 to 0.2. Troponin I didn't have a level. I asked my instructor about the level for that and she said that if it wasn't given than it wasn't ordered for some reason. She honestly acted like I was an idiot for even asking.

There is a risk of electrolyte imbalance with diuretics. I'll have to think about some more. I'm on lunch break at clinicals right now and it's time to go back to the floor.

Thanks for all your help :)

Let you instructor know that he difference between troponin I and troponin T are different abnormal levels. It is important for you to look at the lab reference levels so you KNOW where on the spectrum the patient lies.

So the facility has a higher " normal range.........test results are usually considered normal if the results are:

• Troponin I : less than 10 µg/L
  
• Troponin T : 0–0.1 µg/L
  

[Kuriin, BSN, RN]

Hmmm never even heard of that book. I have Ackley's nursing diagnosis book.

Thanks for the help. I will definitely look for that one :)

Ackley's is what I use. It's perfectly fine. No need to buy another diagnosis book.

[Stoogesfan]

I looked it up in my diagnostics and lab book and it gave these levels:

Troponin T

Troponin I

So are these off?

So I'm confused then. I have been told by my instructors that if I didn't assess something or it's a lab value etc that is CURRENTLY happening I can't use it as data for a nursing diagnosis.

So my client had chest pain and shortness of breath in admission but not since. I saw him over 36 hours after his chest pain and shortness of breath had stopped. That's why I really wasn't focusing on pain.

I really don't mean to sound like such an idiot. All my clients up until now had actual assessment data I could use to formulate diagnosis for and when I seen he had no complaints, no abnormal vitals and according to hospital protocol and my book no abnormal labs I felt so lost. I really do appreciate everyone's help. I want to not just do enough to pass clinical and nursing school, I want to be a good nurse.

[MendedHeart]

What meds are this patient on, do you know what echo showed? Did they do CKs? Heart /lung sounds normal? Any fatigue or DOE?

[MattNurse, MSN, RN]

If this were real life you would focus on the reason for admission. The patient is not left in acute chest pain but still needs interventions to prevent the chest pain from recurring. The nurses are probably intervening and preventing the pain via their care plan, hence why you didn't pick up the pain in your assessment. Also, we don't change a care plan once the issue has resolved. For example if a patient was post op knee and had a femblock to prevent pain and was pain free, my care plan would still include acute pain because we are preventing the pain and intervening. The problem doesn't go away until their is actual resolution or the matter no longer needs focused interventions.

What causes cardiac chest pain? Lack of oxygen to myocardial tissue by occlusion of an artery, leading to anaerobic metabolism, with lactic acid being released. Was your patient on supplemental oxygen? if yes, this could be helping the chest pain by increasing the oxygenation to the heart eliminating the pain. Was he on bedrest? When you get up and move around you need more blood so the heart works more and requires more perfusion.

As an acute care nurse I would not even consider a sugar of 172 a problem, it is ideal for a diabetic to be in that range or slightly lower. That is the only reason I mentioned I would still focus on the chest pain as the main reason that patient is hospitalized. The care plan in reality tells you what you need to focus on and what your interventions should be. We develop a care plan on admission and continue to assess the problem, lets say they determine that the reason the patient came in with acute chest pain was related to not taking his anti-reflux medication and he had gas and ate an extra spicy/fatty meal before bedtime, then you would want to focus on knowledge deficiency, which would be the main root of the acute pain.

It is hard to formulate a care plan without assessing a patient, you have assessed the patient, go with your gut instinct. I just think you could better defend a care plan that addresses the main reason the patient is in the hospital.

So I'm confused then. I have been told by my instructors that if I didn't assess something or it's a lab value etc that is CURRENTLY happening I can't use it as data for a nursing diagnosis.

So my client had chest pain and shortness of breath in admission but not since. I saw him over 36 hours after his chest pain and shortness of breath had stopped. That's why I really wasn't focusing on pain.

I really don't mean to sound like such an idiot. All my clients up until now had actual assessment data I could use to formulate diagnosis for and when I seen he had no complaints, no abnormal vitals and according to hospital protocol and my book no abnormal labs I felt so lost. I really do appreciate everyone's help. I want to not just do enough to pass clinical and nursing school, I want to be a good nurse.

You don't sound like an idiot asking questions, I see the students come to the floor with their nursing instructors and it is frustrating to see how nurses are being trained. They spend more time sitting at the computer looking at labs, H&P's, xray results writing down normal values, the instructors spend 15-20 minutes with the students and don't assess the patient themselves before telling a student what the nursing diagnosis should be. If the patient has a pending stress test echo and it turns up positive you would change your care plan to ineffective tissue perfusion, and negative the care plan would be resolved and patient usually discharged.

[Stoogesfan]

He was on lisinopril, metoprolol, insulin lispro, famotidine, furosemide, fluoxetine, acetaminophen, and simvastatin.

He didn't have the echo while I was there. By the time I came back to clinical he had been discharged. We are only there one day, then off for 2 and come back.

He had no complaints of anything. He said he felt great.

[MattNurse, MSN, RN]

He was on lisinopril, metoprolol, insulin lispro, famotidine, furosemide

Were any of those medications new to the patient?

[Stoogesfan]

The famotidine was new but the rest he had been on for quite some time.