hi, numb2k3, and welcome to allnurses!
learning to choose nursing diagnoses for a nursing student is no different than a medical student who is learning how to diagnose medical conditions. the difference is that we diagnose nursing conditions and we have a work, the nanda taxonomy, to help us out. there are currently 188 nursing diagnoses in the nanda taxonomy and each of them has a list of symptoms (nanda calls them defining characteristics) as well as related factors. each diagnosis also has a definition. if you have a nursing diagnosis book or a care plan book that includes this information for a diagnosis you need to be using it as a reference. this is how you will learn what each nursing diagnosis is all about.
in doing a case study, which is an essay presentation of a care plan, you still follow the nursing process. the nursing process is the problem solving process that we use and it has five distinct steps that you must follow in order:
- assessment (collect data from medical record and by doing a physical assessment of the patient)
- nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
now, you already have assessment data for this patient. that would have been step #1 of the nursing process. for step #2 you need to list this abnormal data and assign nursing diagnoses. this data becomes your signs and symptoms, or defining characteristics
. in looking at the list i see some tests that you probably need to look up so you understand what they are, why they were done and their importance. since this is a case study of a non-existent patient, another thing you should do is look up the medical diagnoses of congestive heart failure and chd (congenital heart disease?). this is a very important component of doing care plans as a student and you need this information in order to understand underlying pathophysiology of what is going on with the patient as well as to increase your understanding of medical disease. a very big lack i noticed in your nursing diagnoses was absence of anything related to the congestive heart failure. pulmonary edema and pleural effusion is a complication of congestive heart failure. congestive heart failure is one of the most commonly occurring heart problems that you will see patients hospitalized and treated for. therefore, you really need to know what it is, how it occurs, its complications, and be familiar with how the doctors treat it. you can find information about many different medical diseases by searching the websites on this listing: your patient's defining characteristics (symptoms) are:
- shortness of breath
- chest pain
- rapid breathing
- decreased breath sounds
- dullness to percussion
- decreased tactile fremitus
- an elevated level of n-terminal pro-brain natriuretic peptide (nt-probnp) - these are markers of congestive heart failure and they increase in proportion to the severity of the patient's heart failure
- supine chest radiograph shows that there is a homogenous increase in density over the lower lung fields and is accompanied by an enlarged heart shadow - this would indicate fluid in the lungs and an enlarged heart
in step #2 of the nursing process, you take this list of defining characteristics and look at the defining characteristics of different nursing diagnoses that you think might fit with what is going on with this patient. you are looking for matches. when a nursing diagnosis reference has the same defining characteristics for a particular nursing diagnosis as your patient, then it is likely that you are diagnosing the patient correctly, but it is also a good idea to read the definition and related factors for that diagnosis to make sure you've nailed it correctly. also, something about the nanda taxonomy that will become very clear to you as a student is that the related factors and defining characteristics will become parts of your 3-part nursing diagnostic statements that your instructors will probably require. it's very convenient then, to have a nursing diagnosis reference to work from so you get these things correct.
these are the nursing diagnoses i would use based on the symptoms from your list above in priority order by maslow:
decreased cardiac output related to altered contractility as evidenced by dyspnea, cough and elevated nt-probnp. [there are more symptoms you could come up with after researching congestive heart failure. this particular nursing diagnosis is almost always used with patients who have congestive heart failure.]
ineffective airway clearance related to excessive mucus (or retained secretions) as evidenced by shortness of breath [or dyspnea], rapid breathing, cough, decreased breath sounds, dullness to percussion and decreased tactile fremitus.
ineffective breathing pattern related to chest pain as evidenced by dyspnea.
risk for ineffective tissue perfusion: cardiopulmonary related to impaired oxygen transport [the problem i am targeting: pulmonary embolism]
risk for excess fluid volume related to excess intake of sodium and water [the problem i am targeting: edema]
risk for injury related to therapeutic puncture of lung [the problem i am targeting: pneumothorax, which is a complication of the thoracentesis]
notice that in these nursing diagnosis statements that the information after the "as evidenced by" are always your patient's actual symptoms that you obtained during your assessment. when you move on the step #3 of the nursing process, your goals and nursing interventions will be specifically aimed at those actual symptoms. there is a very logical way a care plan is constructed.
"risk for" diagnoses are for anticipated problems that you think could occur or you want to prevent from occurring. you need to have a specific problem/ or problems in mind. while you never list any symptoms (defining characteristics) in your diagnostic statement, they are implied. so, for instance, with risk for ineffective tissue perfusion: cardiopulmonary
where i am specifically care planning for a pulmonary embolism i am going to have a list of the signs and symptoms of a pulmonary embolism in my mind although i don't actually list them in the diagnostic statement itself. my nursing interventions for this nursing diagnosis will primarily consist of monitoring the patient for those specific symptoms (and i will list them out on the care plan), perhaps some preventative measures that can be done and what to do if any of the symptoms present themselves. however, the actual diagnostic statement will read: risk for ineffective tissue perfusion: cardiopulmonary related to impaired oxygen transport
and anything about the pulmonary embolism will be included in the goals and nursing interventions. got it? you do the same with the other two "risk for", or anticipatory diagnoses.
now, someone else might disagree and have a different idea of diagnoses to use. that is ok. this is a critical thinking exercise anyway. there were one or two other actual diagnoses that could have been used as well (activity intolerance, fatigue, anxiety, excess fluid volume, impaired gas exchange [you didn't have the symptoms on your list to support using this one]).
if you research chf you can come up with a whole bunch more symptoms to add to the above list which will expand your nursing diagnostic choices.
i given you a lot of help with what to use for nursing diagnoses for this patient. good luck with this assignment.