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?
Just curious -- did they do a d-dimer and/or possibly a CT angio of the chest to rule out PE? Did they do a Chest X ray or a CT chest? I'm surprised there are so little test results for you to go on here.
UM Review RN, ASN, RN
1 Article; 5,163 Posts
Just curious -- did they do a d-dimer and/or possibly a CT angio of the chest to rule out PE? Did they do a Chest X ray or a CT chest? I'm surprised there are so little test results for you to go on here.