give me a nursing diagnosis? please...

1. this is the complaint:
   chest pain during breathing. high fever and chills.
   
   the diagnosis has something to do with the lungs/thorax if that's possible, coz that is what we are studying right now.
   
   i have risk for infection r/t possible exposure to infections in the lungs aeb by fever and chills.
   
   but it doesnt sound right does it?
2. 

   About Animaniacs, BSN

   Joined: Feb '04; Posts: 108; Likes: 4
   RN
   Specialty: 6 year(s) of experience in Med-Surg/Telemetry

   9 Comments

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3. 
   Mar 27, '04

   Joined: Sep '03; Posts: 6,885; Likes: 12,485

   Ineffective Breathing Pattern
   
   Risk of Impaired Tissue Perfusion
   
   Pain
   
   Fear/Anxiety r/t SOB
   
   Ineffective Thermoregulation r/t disease process AEB fever
   
   Hope this gets you on the right track ...
4. 
   Mar 27, '04

   Joined: Dec '03; Posts: 37,336; Likes: 5,525

   What is going to be your most important priority? What do you suspect is going on with your patient? Start with the most important and obvious and work your way down......................I want to see if you can think this through yourself instead of just giving you the answer directly. You will learn more this way...........................
   
   Am here to help you with this................so don't worry.
5. 
   Mar 27, '04

   Occupation: RN Specialty: 6 year(s) of experience in Med-Surg/Telemetry ; Joined: Feb '04; Posts: 108; Likes: 4

   Risk for infection r/t to possible exposure to infection in the lungs aeb fever, chills and pain with breathing.
   
   fever may be a result of something going on inside the body to control/fight off infection or else the client would not have a fever and chills.
   
   then the pain in the lungs may indicate an infection that has gotten there and thats how it all started.

   Last edit by Animaniacs on Mar 27, '04
6. 
   Mar 28, '04

   Occupation: student Joined: Jun '03; Posts: 159; Likes: 65

   I think Acute Pain would be your primary dx.
   You could also use anxiety, ineffective breathing pattern, activity intolerance and probably several others
7. 
   Mar 28, '04

   Joined: Dec '03; Posts: 37,336; Likes: 5,525

   The patient is not at risk for infection, he already has an infection if he has a high fever and chills.
   Would pain be your primary concern? No.
   Think breathing.......................patient has chest pain with taking a deep breath, so his respiratory status is going to be compromised. Respiratory is always going to be first when considering this type of patient. If he isn't taking a deep breath, what is his oxygenation going to be like?
   
   Now go from here..........................
8. 
   Mar 28, '04

   Joined: Dec '03; Posts: 143; Likes: 10

   Ineffective Breathing Pattern
   ABC,s always. If patient is having pain from breathing than you can expect more problems developing.
9. 
   Mar 28, '04

   Occupation: Remote OASIS and Coding Reviewer Specialty: 13 year(s) of experience in Home Health ; From: TX, US ; Joined: Aug '03; Posts: 870; Likes: 99

   I'm with Suzanne...ABCs...breathing is always (most of the time) primary concern. I love Suaznne, the way she takes you through the process, like an instructor. It is truly the way to learn in lieu of being given the answer.
10. 
    Mar 28, '04

    Occupation: New RN Grad... Just passed NCLEX.. Working on a Ortho floor Joined: Nov '01; Posts: 1,616; Likes: 37

    I agree.. Remember your ABC's.... They make some excellent nursing diagnosis books...
11. 
    Mar 28, '04

    Occupation: RN Specialty: 4 year(s) of experience in Trauma ICU, MICU/SICU ; Joined: Sep '03; Posts: 1,119; Likes: 113

    Great responses. Also, always remember, risk diagnoses NEVER have s/s. It has not happened yet.
    
    For example, Risk for falls r/t impaired mobility. No AEB because there is no evidence of a fall.

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