Am I writing this nursing diagnosis correctly?

psu_213, BSN, RN · Sep 2, 2012

Ok, my patient has tachycardia (asymptomatic). The 2 nursing diagnosis I chose are:
Impaired tissue perfusion R/T inadequate ventricular filling associated with tachycardia AMB heart rate ranging from 80's-130's
and
Decreased cardiac output R/T inadequate ventricular filling associated with tachycardia AMB???
Did I format these correctly? Does that sound right?

For the dx. of "Impaired tissue perfusion"-- you need to change your symptoms (AMB). The high HR is not a symptom of the impaired tissue perfusion, it may be the cause. Based on the high heart rate, you can say that they are tachycardiac, but tachycardia is not a symptom of impaired tissue perfusion. When you assess your pt, how can you tell that they have impaired tissued perfusion--i.e. what are the symptoms of this problem?

lovetosleep · Sep 2, 2012

Thank you so much for the help. The patient is completely asymptomatic. Do I need to change both of them to risk for?

Esme12, ASN, BSN, RN · Sep 2, 2012

If your patient has asymptomatic tachycardia........why does it need a nursing diagnosis?

What is the patients complaints? What is your assessment.

This is a common mistake many students make they get a diagnosis and try to fit it to the patient. When it is actually the other way around.

The biggest thing (First) a care plan is the assessment. The second is knowledge about the disease process. First to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

The third is a good care plan book. I use ackley: nursing diagnosis handbook, 9th edition and gulanick: nursing care plans, 7th edition

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. One of the main goals every nursing school wants its RNs to learn by graduation is how to use the nursing process to solve patient problems.

Just like you need a recipe care to make a cake from scratch. A care plan is your recipe card to caring for your patient and what to look for while you are caring for them.

So your patient has a history of What? and complains about......?.

The construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during your assessment of the patient. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals. from our beloved daytonite:RIP

in determining a problem you should always use the nursing process. first, look at the assessment data you have. . .

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

What I would suggest you do is to work the nursing process from

step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). The adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming...........and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? If so, now is the time to add them to your list. This is all part of preparing to move onto......

step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

care plan reality: what you are calling a nursing diagnosis (ex: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis

Now what information about your patient do you have....

lovetosleep · Sep 2, 2012

Hi Esme,

Our teacher says we have to have to choose 2 physiological nursing diagnosis for our patients. I am having a really hard time with this because the asymptomatic tachycardia is the only abnormal thing this patient has. His physical assessment was completley normal. He went to the Dr for a check up, they noticed his heartrate was abnormal, and admitted him for a work up. He has a pacemaker that was not working. They reprogrammed it and discharged him.

allnurses Guide · Sep 2, 2012

Hi Esme,
Our teacher says we have to have to choose 2 physiological nursing diagnosis for our patients. I am having a really hard time with this because the asymptomatic tachycardia is the only abnormal thing this patient has. His physical assessment was completley normal. He went to the Dr for a check up, they noticed his heartrate was abnormal, and admitted him for a work up. He has a pacemaker that was not working. They reprogrammed it and discharged him.

Are there some nursing dx that you can think of that accompany a hospital admission?

Esme12, ASN, BSN, RN · Sep 2, 2012

So my question to you is ....why did he have a pacemaker? Was his pacemaker for Tachycardia? What meds was he on? What kind of pacemaker was it? Why was is malfunctioning? What is tachycardia? What can happen with symptomatic tachycardia? What are the defining features of impaired tissue perfusion?

If his heart rate went too fast what would it put him at risk for? So the patient would be at risk for......... R/T tachycardia due to inadequate ventricular filling as evidenced by.......... Make sense?

I have to dash...I will be back. Tell me about your patient. What were the vitals? What other physiologic diagnosis is there that can be associated with the malfunctioning pacemaker. What is in the history that the tachycardia was such a concern that it required hopsitalization on a rapid asymptomatic fast pulse in the office....there is more to the story.

lovetosleep · Sep 2, 2012

Are there some nursing dx that you can think of that accompany a hospital admission?

I can think of lots of psychosocial nursing dx that accompany a hospital admission, but no physiological dx. His only physical problem was the tachycardia.

lovetosleep · Sep 2, 2012

So my question to you is ....why did he have a pacemaker? Was his pacemaker for Tachycardia? What meds was he on? What kind of pacemaker was it? Why was is malfunctioning? What is tachycardia? What can happen with symptomatic tachycardia? What are the defining features of impaired tissue perfusion?
If his heart rate went too fast what would it put him at risk for? So the patient would be at risk for......... R/T tachycardia due to inadequate ventricular filling as evidenced by.......... Make sense?
I have to dash...I will be back. Tell me about your patient. What were the vitals? What other physiologic diagnosis is there that can be associated with the malfunctioning pacemaker. What is in the history that the tachycardia was such a concern that it required hopsitalization on a rapid asymptomatic fast pulse in the office....there is more to the story.

He did not have any history in the chart. He said this is the first time he has been to the Dr since he was a child. I think the lack of history prompted them to send him in for evaluation. He said he got the pacemaker when he was a small child in another country and did not remember why. I dont know what type of pacemaker it was, but report in the chart said the pacemaker was "failing to capture and or sense" All of his labs were normal and he did not take any meds.

If the tachycardia was symptomatic he may have chest pain, dizziness, SOB, syncope, not be able to feel peripheral pulses. So he would be at risk for decreased cardiac output, decreased tissue perfusion, falls. Am I on the right track now?

His vitals were BP 125/81, T 98.1, spo2 99%, RR 15. The pulse was anywhere from 85-110 when resting, and activity brought it up to 120's-130's. He denied chest pain, SOB, dizziness.

Esme12, ASN, BSN, RN · Sep 2, 2012

There you go.......now you are on the right track.

So your patient is at risk for impaired tissue perfusion R/T inadequate ventricular filling associated with tachycardia AEB chest pain, dizziness, SOB.

Your patient is at risk for falls/inadequate safety/alteration in comfort(chest pain)/decreased ADLs (fatigue due to decrease cardiac output, chest pain with activity) R/T inadequate ventricular filling associated with tachycardia and decreased cerebral perfusion AEB syncope.....

Do you see where this is going??

Good job!!!!!!

lovetosleep · Sep 3, 2012

Thank you Esme!!! :)

Esme12, ASN, BSN, RN · Sep 4, 2012

YOU're welcome.:)