nursing dx/care plan help needed

  1. 0
    i would love some second thoughts on this!

    i have to come up with three priority nursing dx for a pt who presented with chest pain. prior medical hx of microvasc. angina, pot syndrome, chronic fatigue, fibromyalgia, ibs, celiac.

    current assessment data as follows, arranged in gordon's functional health patterns:
    health perception-health management.
    views health as poor. sees an acupuncturist for pain control. non-drinker and non-smoker. interest is shown in a cardiac rehabilitation program. full-code status. multiple chronic conditions including fibromyalgia, pot syndrome, and the related pain and depression. expresses concern at the lack of continuity of nursing care during her hospital stay.
    nutritional-metabolic
    26 lb weight gain in the past 6-8 months. a recent endoscopy revealed an increase in eosinophils in throat due to multiple severe allergies according to patient report. 75% of tray consumed on average each meal. refuses to comply with the cardiac diet requested; observed eating outside food each time room was entered . multiple food allergies, follows gluten free diet. skin integrity appeared intact. skin appeared free of lesions, warm, dry, color normal for ethnicity. patient had port-a-cath in central line, dressing intact, no discharge visible. a clonidine hcl patch adhered to upper left arm. oral temperature measured 37.1, weight measured 109 kg with height measuring 5 feet 7 inches.
    elimination
    history of ibs and celiac. celiac sprue were visualized on past colonoscopy. pt has not had bowel movement since thursday, . has bowel movement at home due to calm (brandname) magnesium supplement. not taken it during hospitalization. urine output 600 ml over 6hr period. urine appears yellow in color, free of sediment, and lacks strong odor. concern about “urine being tested” prior to discharge.
    activity-exercise
    frustration with her constant fatigue. uses 3 pillows each night in recliner to sleep. pot syndrome and fibromyalgia prevent from getting exercise, performs activities of daily living at home “okay”. currently takes atenolol. hypercholesteremia. interest in cardiac rehabilitation program. breath sounds auscultated bilaterally in upper and lower lobes. heart sounds auscultated, s1 and s2 present. capillary refill appears less than 2 seconds, sensation and mobility observed as intact. possible swelling in right lower extremity noted. non-pitting +2 edema observed around ankle and dorsal surface of foot. bp observed 99-112/58. respirations observed at 14 breaths per minute, with a pulse rate of 85 beats per minute. oxygen saturation appears sufficient at 95% on room air. troponins less than 0.03, ecg showed st wave elevation on admission, myocardial perfusion scans show adequate perfusion with ef of 54%. no signs of coronary artery disease .
    sleep-rest
    recliner used nightly for sleeping. patient reports frequent naps that do nothing to relieve exhaustion or renew energy.
    cognitive-perceptual
    chronic pain at best 6/10, at worst 9/10. recently started taking pregabalin (lyrica) for fibromyalgia. alert and oriented times three prior to receiving meds, post medication, oriented to place and person, but not time and expresses confusion over the day and order of events of hospitalization. patient reports vision is decreasing, pupils are staying dilated and cannot read as well. expresses frustration with memory functions. takes venlafaxine, clonidine hcl, and fentanyl for pot/fibromyalgia pain. pupils are round, reactive to light and accommodation.
    self-perception-self-concept
    receives disability, and views personal health as poor. recently had a positive nasal swab for mrsa. feelings of limitation due to her pain from her chronic conditions. appears distracted with poor eye contact.
    role-relationship
    patient expresses anxiety about recent mrsa diagnosis, verbalizes fears that daughter will not let pt see the grandchildren, believes daughter to be unreasonable about fears of contagion. husband appeared interested in program of care, spent time in room reading materials on mrsa. he verbalized that he hoped enough information would satisfy their daughter.
    sexuality-reproductive
    married for 24 years, gravida 2 para 2. post-menopausal, no contraception used. patient also verbalizes lack of sexual desire due to polypharmacy.
    coping-stress
    in process of moving from home to an apartment. husband and daughter are primary sources of emotional support. appears tearful and distraught each time room is entered. fears about lack of positive findings on her cardiac function tests. just wants to know why she is having so much pain. tangled self in iv/pca lines, became tearful. uses multiple medications to cope with fear and anxiety, and requests ativan/benadryl together. takes venlafaxine in addition to lorazepam, benadryl, clonidine hcl, pregabalin, and fentanyl.

    value-belief
    seeks acupuncture care on a regular basis. utilized the hospital chaplain during recent hospitalization. attends church at home when health permits. does not plan much for the future because believes health status to be precarious.

    okay, sorry for the funky format. so that is all my assessment data.
    pt was being discharged, chest pain was attributed by doctors to be from the microvasc. angina or the pot syndrome, not mi

    so, i've pulled together
    1. activity intolerance r/t chronic pain aeb pt stating,"my pain and fatigue really limit what
    i can do"

    2. chonic pain r/t disease state aeb pt reporting " i came in when accupuncture wasn't working anymore"

    3. imbalanced nutrition: more than body requirements r/t intake greater than metabolic need aeb bmi greater than 35.

    am i on the right track? i feel kind of confused by the presenting chest pain that was attributed to her chronic conditions by the physician. all the heart function tests showed her heart function is within normal limits, so i didn't go with cardiac output, decreased, her breathing was fine, really her anxiety

    was another big issue, but i was trying to choose physiological rather than psychosocial. okay, any other thoughts will be much appreciated!
    thanks in advance, ns
  2. 6 Comments so far...

  3. 3
    why does she have the port-a-cath? what medication does she receive through it? she was admitted with chest pain so they did a cardiac workup, right? otherwise, she has these other chronic problems. pain is a big issue in her life as is dealing with fear and anxiety ("uses multiple medications to cope with fear and anxiety"). did you do any reading about fibromyalgia? (http://www.merck.com/mmpe/sec04/ch040/ch040d.html) her chronic fatigue is probably related to it. most people with fibromyalgia have chronic fatigue. they are also on multiple antidepressants and have sleep difficulties. with her celiac disease was there any labwork that showed nutritional deficiencies. with her overweight and bmi of 35 it sounds like she and her ibs are doing ok outside of some constipation.

    the first thing i did was make a list of your abnormal data. abnormal data becomes the evidence to support nursing diagnoses. interesting information emerges:
    • sees an acupuncturist for pain control
    • 26 lb weight gain in the past 6-8 months
    • weight 109 kg/height measuring 5 feet 7 inches [109 kg = 239.8 pounds]
    • refuses to comply with the cardiac diet
    • multiple food allergies
    • follows gluten free diet.
    • no bowel movement since thursday
    • uses calm (brandname) magnesium supplement for bm
    • constant fatigue
    • capillary refill less than 2 seconds
    • non-pitting +2 edema observed around ankle and dorsal surface of foot
    • reports frequent naps that do nothing to relieve exhaustion or renew energy
    • not oriented to time and expresses confusion over the day and order of events
    • reports vision is decreasing and cannot read as well
    • expresses frustration with memory functions
    • positive nasal swab for mrsa
    • pain from her chronic conditions - where is this pain?
    • poor eye contact during conversation
    • anxious about recent mrsa diagnosis
    • verbalizes fears that daughter will not let her see her grandchildren
    • believes her daughter to be unreasonable about fears of contagion
    • husband seems interested in program of care and spent time in room reading materials on mrsa and verbalized that he hoped enough information would satisfy their daughter
    • tearful and distraught each time room is entered [this is due to self-pressure and stress to perform well. patient's with fibromyalgia are often perfectionists who get upset at themselves for not performing well. a hospitalization is seen as a failure.]
    • wants to know why she is having so much pain - is this her confusion? she has fibromyalgia. does she not understand the pain is a result of this?
    • uses multiple medications to cope with fear and anxiety
    construction of the 3-part nursing diagnostic statement is as follows:

    p (problem, the nursing diagnosis) - e (etiology, the cause of the problem) - s (symptoms, the proof that the problem exists)
    1. activity intolerance r/t chronic pain aeb pt stating,"my pain and fatigue really limit what
    i can do"
    the definition of this diagnosis is insufficient physiological or psychological energy to endure or complete required or desired daily activities. necessary to the presence of this problem is that the heart and lungs of the patient be stressed during activity. heart rate and breathing must be elevated during activity. there must be dyspnea. ultimately the patient gets fatigued and must end up stopping the activity. the word deconditioning is often used with this diagnosis. chronic pain is not an acceptable related factor for this diagnosis. it has nothing to do with causing deconditioning. also, pt stating,"my pain and fatigue really limit what i can do" is not evidence that proves the patient has no energy to perform physical activity. you need some physical proof such as an elevated heart rate or respiratory rate when the patient begins physical activity, exertional dyspnea, or reporting this fatigue after a period of activity, such as "i just can't go any further".
    2. chonic pain r/t disease state aeb pt reporting " i came in when accupuncture wasn't working anymore"
    the listing disease state in the nanda taxonomy is a guideline since they can't list all the actual diseases that cause chronic pain. and, we can't state the actual medical disease. it is the fibromyalgia. you need to turn that into generic medical terminology. the cause of fibromyalgia is unknown but the pain is due to stress in the muscles and tissues. pt reporting " i came in when accupuncture wasn't working anymore" is a comment about her treatment and is tells nothing about the symptoms of her pain.

    assessment and description of pain includes the following (you might want to copy these down):
    • 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
    3. imbalanced nutrition: more than body requirements r/t intake greater than metabolic need aeb
    bmi greater than 35.
    there is other evidence that you forgot to add: current weight is 109 kg/height measuring 5 feet 7 inches [109 kg = 239.8 pounds], has had 26 lb weight gain in the past 6-8 months, refuses to comply with the cardiac diet, and has multiple food allergies
    i would use anxiety r/t stress and family relationships aeb poor eye contact during conversation, current reaction over recent mrsa diagnosis and how it will affect her relationship with her grandchildren and she fears that her daughter will not let her see her grandchildren and believes her daughter to be unreasonable about contagion and becomes easily tearful when she feels she is not performing as well as she could.
    cooliegirl, suzy253, and aguacates11 like this.
  4. 0
    Daytonite, Thank you so much for your thoughtful answer! It definitely pointed me in the right direction, I think this is a good care plan for me to work on, as I have a harder time writing dx without lab results or positive tests to back things up. All her labs were w/in normal ranges. Her cardiac workup was essentially normal. The port-a-cath is supposedly due to bad veins, it had been placed previously in another facility. I think she was getting her PCA fentanyl through it? I did do a ton of reading about fibromyalgia and POT syndrome, the pt felt that her current pain was unrelated, even though her physicians thought the pain was related to her chronic conditions.

    Okay, revised versions...

    1.Activitiy intolerance r/t sedentary lifestyle secondary to autonomic dysfunction AEB pt experiencing discomfort with exertion and stating," My heart races and I can't breathe after I move too much"

    Okay, must go wake up kids for school, I'll be back in a bit with the rest.

    Daytonite, thanks again!
  5. 0
    Okay, after a little tweaking, this is what I'm working on

    1. Activity intolerance r/t sedentary lifestyle secondary to autonomic dysfunction AEB pt experiencing discomfort with exertion and stating, “My heart races and I can’t breathe after I move too much”

    2. Chronic Pain r/t stress in tissues and muscles secondary to fibromyalgia AEB patient rating pain as 6/10 at best and 9/10 at worst, crying and moaning, and restlessness in bed.

    3. Anxiety r/t stress and family relationships AEB poor eye contact during conversation, quickly responding to staff with tears when she feels she executes tasks poorly, current reaction over recent MRSA diagnosis and how it will impact her relationship with her family, she fears that her daughter will not let her see grandchildren and believes her daughter to be unreasonable about fears of contagion.

    I listed them in this order because #1 is resp/cardiac, #2 is pain, and #3 is a psychosocial dx

    Do these look a little better? Thanks in advance!
  6. 1
    definitely, improved! the sequencing is correct. there is just one comment that i have and that is about the activity tolerance. . .
    1. activity intolerance r/t sedentary lifestyle secondary to autonomic dysfunction aeb pt experiencing discomfort with exertion and stating, “my heart races and i can’t breathe after i move too much”
    when using "secondary to" in the related to part of the diagnostic statement it is a way of sneaking in the medical diagnosis. is autonomic dysfunction a medical diagnosis? or, is it a symptom of the fibromyalgia? why not just leave it out? read the list of related factors for this diagnosis. it isn't important that autonomic dysfunction is causing the problems with the heart and respiratory rates. what is important is that they are caused by inactivity (deconditioning).
    2. chronic pain r/t stress in tissues and muscles secondary to fibromyalgia aeb patient rating pain as 6/10 at best and 9/10 at worst, crying and moaning, and restlessness in bed.

    3. anxiety r/t stress and family relationships aeb poor eye contact during conversation, quickly responding to staff with tears when she feels she executes tasks poorly, current reaction over recent mrsa diagnosis and how it will impact her relationship with her family, she fears that her daughter will not let her see grandchildren and believes her daughter to be unreasonable about fears of contagion.
    when you move on to write your goals and nursing interventions they specifically target your aeb items for each physiological diagnosis. for the psychosocial diagnosis (anxiety) you can also target the related factors.
    aguacates11 likes this.
  7. 0
    Daytonite, thank you so much for taking your time to help! I listed the autonomic dysfunction because it is what is going on with the POT syndrome (heart races when pt stands up, is thought to be due to autonomic dysfunction), perhaps it is not helpful as part of activity intolerance? I was thinking about how it relates to the activity intolerance, but really it is the patient's perception of it that is the limiting factor. Maybe I am just confusing myself now...
  8. 0
    if her heart races when she stands up and begins moving that is empirical evidence of activity intolerance and not a cause of it. if you actually have a pulse measurement of this it should be included with your aeb evidence. however, it is the pot syndrome that is the cause and that needs to be stated in a generic way as the related factor in your diagnostic statement because sedentary lifestyle is not the real cause.
    • activity intolerance r/t imbalance in autonomic nervous system control of blood flowsecondary to pot syndrome aeb pt experiencing discomfort with exertion and stating," my heart races and i can't breathe after i stand up and begin to move."
    • or, just. . .activity intolerance r/t imbalance in autonomic nervous system control of blood flow aeb pt experiencing discomfort with exertion and stating," my heart races and i can't breathe after i stand up and begin to move."
    http://www.dinet.org/pots_an_overview.htm - pots: an overview


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