I am really confused. My patient (73 y.o female) was brought to ER for unresponsiveness. Her labs show high cardiac enzyme levels (troponin & CK-MB) indicating she had a MI. On top of this she has been treating Bronchitis with a Z-pak for a week with no success. Now she has pneumonia. When writing up my care plan which medical diagnosis should I focus on? Which is priority? I want to say pneumonia because its causing respiratory problems from excess mucus and infection which would lead to more problems due to improper oxygenation, however, with a heart attack (She had stents placed) circulation is a problem which could lead to more problems also.
She was coughing, but infrequently and it wasn't very forceful. She was able to expel some mucus that she would spit into a tissue and wipe away. It was yellow/green and thick. I reminded her to use incentive spirometer and was able to have her demonstrate for me 3 times before the end of my clinical day. I heard some crackling in her lungs at the base of both when I listened posterior side. Her temp stayed around 99 during my shift. Her admission temp was 104. Respirations appeared normal 18-20 per minute. She was not breathing heavily. She would reach 1000 during inspiration on the incentive spirometer.
Now she also has a fever and edema. She is on anti-coagulants and diuretics (if she still is).
What I see....in no specific order
Activity Intolerance: c/o fatigue and SOB with ambulating to the BR
Ineffective Airway Clearance: cough pt C/O no being able to get up secretions
Risk for Bleeding: anti-coagulants
Risk for decreased Cardiac tissue perfusion: heart cath, stent placement
Risk for Electrolyte Imbalance: diuretics
Risk for Falls: fatigue, sob, frequent toileting from diuretics
Excess Fluid Volume: edema crackles
Hyperthermia: fever
Bathing Self-Care deficit: requires assistance
Decreased Cardiac Output: edema crackles
Can Hypertension be used as a related to factor for nursing diagnosis: Risk for decreased Cardiac tissue perfusion? Or must it be reworded to say High blood pressure because hypertension is a medical term and medical diagnosis?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
She was coughing, but infrequently and it wasn't very forceful. She was able to expel some mucus that she would spit into a tissue and wipe away. It was yellow/green and thick. I reminded her to use incentive spirometer and was able to have her demonstrate for me 3 times before the end of my clinical day. I heard some crackling in her lungs at the base of both when I listened posterior side. Her temp stayed around 99 during my shift. Her admission temp was 104. Respirations appeared normal 18-20 per minute. She was not breathing heavily. She would reach 1000 during inspiration on the incentive spirometer.
Still you have evidence that supports this and she did verbalize that she couldn't cough it up effectively.
Since her temp for you was 99.OF hypethermia was not a priority for you....remember hyperthermia is defined as: a rise in the core body temperature to 1° to 2° C higher than the client’s normal body temperature.
Remember care plans priority is determined by the ABC's and Maslow's Heirarchy. What can kill or hurt them first. Risk of diagnosis ae considered real diagnosis and can be high on the priority list.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Can Hypertension be used as a related to factor for nursing diagnosis: Risk for decreased Cardiac tissue perfusion? Or must it be reworded to say High blood pressure because hypertension is a medical term and medical diagnosis?
You can use HTN as a description of the diagnosis. Yes....it is in the defining characteristics: Hypertension; hyperlipidemia; cigarette smoking, family history of coronary artery disease; diabetes mellitus; alcohol and drug abuse, obesity, cardiac surgery; hypovolemia; hypoxemia; hypoxia; coronary artery spasm; septic shock, cardiac tamponade; birth control pills, elevated C-reactive protein; lack of knowledge of modifiable risk factors (e.g., smoking, sedentary lifestyle, obesity)
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I have 10th edition. I looked in Ackley and see it listed only as Risk. Ok, I will stay away from diagnosis that are not NANDA approved.
The proper way is to use only NANDA approved diagnosis....I would hope your school has the same "standard" however I know there are programs/schools out there that take some literary privilege and allow certain things outside the "standard".
Thank you for the time you spent to answer my questions. It helped me to better understand the nursing diagnosis process. I have since graduated and passed NCLEX. :)
sjmadailey
11 Posts
Infection is listed in the careplan book as a nursing diagnosis, but I see what you are saying. It's not NANDA dx.