Confused: Nursing Diagnosis

vashtee, RN · Sep 28, 2008

His respiratory rate is a normal value, and since you don't list any abnormalities in the depth or effort of breathing, I don't think I'd use "ineffective breathing pattern" at all. I'd probably go with " acute pain" for your priority diagnosis.

Knowledge deficit always works, and perhaps some sort of anxiety diagnosis r/t his not knowing his health status?

gaajr1, RN · Sep 28, 2008

Thanks natania! I knew I wa doing something wrong. The only reason I picked ineffective breathing pattern was because patient says I can't breathe properly. But as you said there is no objective data to back it up.

I will try writing the 3 diagnosis again. Thanks again!

gaajr1, RN · Sep 28, 2008

Okay, I rewrote the diagnosis, could anyone please tell me if this is right? This is towards my first care plan. Thanks a lot!

1. Acute pain r/t musculoskeletal pain AEB facial grimaces, pain 7/10 scale, and patient states, "my chest hurts", "I feel I can't breathe properly".

2. anxiety r/t perceived threat to physical and emotional integrity AEB feelings of helplessness and discomfort.

3. Deficient knowledge r/t to new condition, procedure, and treatment AEB denial of ned to learn and patient states, "I don't know why I have chest pain".

impress0508 · Sep 28, 2008

scrubaway010 said:

I'm really lost in prioritizing the nursing diagnosis for the following patient.
He is 41yrs

admitting dx chest pain rule out MI

his bp 118/68, RR- 18 bpm

chest pain since 3 days

pain 7/10

Pt states: "my chest hurts", "I feel I can't breathe properly", facial grimaces.

since 2/3 months 10 people live with him; "don't like lot of people", likes to be left alone.

No Past medical history.

Troponin values are normal

BUN/Creat ratio is low

Meds: morphine sulphate 2mg/IV Q2PRN pain

nitroglycerine 0.4mg/SL PRN for chest pain

ondansetron 4mg/IV Q6H PRN

Zolpidem Tartrate 5mg/PO

aspirin daily

For my first nursing diagnosis, can I write:

Ineffective breathing pattern r/t pain AEB facial grimaces, pain 7/10, and patient states, "my chest hurts"

Under planning/goals:

Patient will maintain regular breathing pattern AEB pain 2/10 scale by the end of shift.

For my second:

Can I use activity intolerance?

third:

knowledge deficit?

I'm not sure if I'm prioritizing right. I kind of feel lost, could anyone please tell me what I'm doing wrong and if my selection of diagnosis is right?

Thanks a lot!

This is the important part of developing a nursing diagnosis: What was your assessment? This is what you have listed

Subjective: "my chest hurts", pain 7/10, "I fell I cannot breath properly", chest pain for three days

Objective: Facial Grimices, No PMHX, Admission Chest Pain R/O MI, VS: 118/68, RR: 18 (No Pulse or Pulse ox?), Troponin: Normal

What was your physical assessment? You can also obtain information to support your nursing diagnosis. You need data to support your choice of diagnosis since this is essentially your proof of your choices. Now from what you have written in priority of diagnosis:

Acute pain r/t (need more information to determine this)

To support impaired breathing or impaired oxygen you need information regarding Lungs (Clear???), Oxygen sat???,

Knowledge deficit: you need to substantiate this with more information.

Activity Tolerance: What information here can show proof of this???? You do not define what activity he can or cannot perform. Does he have problems with ADLS????

He does not like to be around people and likes to be alone? In affect this may have to deal with coping, but again not enough information to determine if this is his usual pattern.

Therefore you need to have more data to determine your priority nursing diagnosis. Pain can be proven, however the related factors need more information. This patient has normal labs, yet no pulse is written so could it be decreased cardiac output??? impaired tissue perfusion-cardiac???, anxiety (mild), etc. Also as to SOB, could this be due to anxiety??? which is causing the pain to chest??? You are missing vital information, if you had a head to toe assessment and highlighting your abnormals, you will then have the data to be able to formulate the nursing diagnosis for this patient.

Hope this helps. :typing

Daytonite, BSN, RN · Sep 28, 2008

Care planning is all about determining a patient's nursing problems and developing strategies to improve, stabilize or support the deterioration of them. To do that we use a 5-step tool called the nursing process to help us. When you sit down to actually document your critical thinking, you should follow these five steps in the sequence that they occur to help keep you focused and organized:

Step 1 Assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - look up myocardial infarction and why a person has chest pain with it. Find out why a person has chest pain with any kind of heart related problem. You need to know this for the etiology of your acute pain diagnosis and whether or not you decide to also use a diagnosis of decreased cardiac output. Look up the reasons for the drugs that are being given to this man who has no prior medical history. He is being sedated, no cardiac meds.

chest pain rule out mi

Step #2 Determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is the important data I picked up from your three posts

chest pain for 3 days - pain 7/10
"my chest hurts"
"I feel I can't breathe properly"
facial grimaces
10 people live with him for the past 2/3 months
"don't like lot of people"
likes to be left alone
feelings of helplessness and discomfort

Step #3 Determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - use that list above to match with defining characteristics listed under nursing diagnoses that seem to apply to your patient's situation. If a symptom isn't listed with a nursing diagnosis, it's a good bet that you are diagnosing the problem wrong and need to keep looking for another diagnosis. Prioritize by maslow's hierarchy of needs (https://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs)

acute pain r/t inadequate oxygenation of heart tissue aeb chest pain for 3 days of 7 on a scale of 10, facial grimacing, and patient statement "my chest hurts"
anxiety r/t stress aeb nausea [is on something for nausea], feelings of helplessness and discomfort, patient statement "I feel I can't breathe properly"
ineffective role performance r/t stress and conflict aeb ten people have been living with him for the past 2/3 months, likes to be left alone, and patient statement "don't like lot of people"
if you want, do deficient knowledge, procedures r/t lack of information aeb []

Acute pain r/t musculoskeletal pain aeb facial grimaces, pain 7/10 scale, and patient states, "My chest hurts", "I feel I can't breathe properly".

Your etiology is wrong. See above. Pain is due to an injury or assault to the tissues of some kind.

Deficient knowledge r/t to new condition, procedure, and treatment aeb denial of need to learn and patient states, "I don't know why I have chest pain"

Do we even know why the patient is having chest pain? It's probably anxiety and role responsibility related to stress in his life. Include teaching interventions with the anxiety diagnosis.

In working on this I couldn't help but think that this man was having panic attacks. What is missing is the rapid respirations (tachypnea) that would cause hypoxia that would lead to the chest pain. This seems to have more of a psychosocial slant than a physiologic one. However, you saw the patient, not me. The docs are going to rule out a cardiac cause of the problem first.

gaajr1, RN · Sep 28, 2008

impress0508 and Daytonite, thanks a lot for your replies.

What you tell me makes perfect sense but when I assessed this patient he had no abnormal findings, to substantiate his chest pain. I have all the info I need in front of me. I wrote the patho, meds and labs and couldn't relate his chest pain to MI. Instead, was leaning all the time towards anxiety as a possible reason but at the same time was confused and didn't know how to relate the chest pain.

I don't know if I'm just stupid but had a hard time with a simple case. On the other hand in post conference had a complicated case and could answer questions better. At times I feel so incompetent and wonder if I can do this at all. Infact, yesterday after I posted my question, I just broke down not being able to think straight.

Sorry, for venting out and thanks again for the help. I will keep trying and hope to do better next time.

Daytonite, BSN, RN · Sep 28, 2008

If anything, this should point out to you that we are diagnosing nursing problems, not medical problems. The nursing diagnoses are specifically designed to do that. This is how they differ significantly from medical diagnoses. That's why you assess and look at the handful of symptoms you've got--not the medical diagnoses so much. Maybe because I'm a disinterested 3rd party I saw it much clearer, but the evidence of a heart problem wasn't there. But the psychosocial evidence was building up. Actually, you had pretty good assessment of that! I'm not that good at psych, but you did a good job of it!

gaajr1, RN · Sep 29, 2008

Daytonite, the words of encouragement means a lot to me. I will do whatever hard work it takes to learn things, but the past week between tests, clinicals and home I was really overwhelmed. I was feeling bad for not doing enough for kids and I was just distraught.

Thanks for being there for all of us. Take care.

veleron · Sep 29, 2008

i think the best way to really get the problem of your patient is to look at his chart....thats what i do anyway ^^.......any information regarding your patient prior to his admission is in the pt. chart....and also you can't relate MI with his symptoms because it was already ruled out right? but he still has angina so you can research for any possible nursing diagnosis for angina. but the best thing you can do right now is look for the doctor's diagnosis. in that way you can research abnormalities that can be experienced by a pt related to the doctor's diagnosis and then compare it to you pt's situation and then make a nursing diagnosis and intervention about that ^^ but i think your data is lacking...i mean if he has a pain scale of 7 for 3 days then he should have a hightened RR right?? a pain scale of 7 is already very painful

hahaha just sharing what i think...i could be wrong you know....im still a 3rd year student ^^ please correct me so i can reflect on it.....especially daytonite ^^

gaajr1, RN · Sep 29, 2008

veleron, the patient was admitted on Thurs night and MI is still not ruled out, for they wanted him to go for a stress test. The patient was NPO after b'fast and test was scheduled at 3pm. For whatever reason the test was cancelled.

I have looked at the face sheet, labs and meds. All his vitals are within normal limits. The meds he is getting is for pain and prophylaxis for MI, N/V. He can do everything self. I was there when the test was called off, and I could see a dramatic change in the way he was talking to me. Could be because his pain level was less. He is also in denial that this could happen to him, and the main stressor is having 10 people living in his house. I asked him if he was financially supporting them, and he said no. He is a writer and likes to be by himself. Before leaving I went to check him and he said I feel like partying!!

I had to write the patho for MI, as it's still not ruled out. But as I mentioned before could not relate his symptoms with it. So, when Daytonite explained, things got clear.

I'm a first year student, had only 4 clinicals so far and just getting a grasp of things. At times the light bulb turns on and sometimes it doesn't. Thanks a lot for the input, I will keep it in mind.:wink2:

vashtee, RN · Sep 30, 2008

The fact that his troponin levels were normal points away from an MI. That's why I would use "pain" as a priority diagnosis. He hasn't had a heart attack, but perhaps anxiety or angina?

Confused: Nursing Diagnosis

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