Published
3. acute chest pain r/t atherosclerosis and coronary spasm aeb substernal, aching, level 5 pain
5. powerlessness r/t chf aeb expression of having no control over situation or outcome
your care plan is for a window in time. if you do not feel comfortable that these are actual problems for that window when you had the patient then turn them into anticipated problems. i'm looking at her history. with atherosclerosis, cardiomyopathy and a history of an mi, she has chest pain, dyspnea and activity intolerance to look forward to. about the only diagnosis i might change would be acute pain to risk for acute pain meaning angina. if activity brings on angina, however, it is an actual problem.
wow! thanks so much for your help! a few more questions if you don't mind...how do these sound...
nursing diagnoses ***in priority order***
1. decreased cardiac output r/t cardiac arrhythmias aeb atrial fibrillation on ekg
does ineffective breathing take priority over decreased co (referring to abcs)?
2. ineffective breathing pattern r/t acute chest pain aeb dyspnea
is it ok to say r/t acute chest pain even though her pain has gone away?
3. acute chest pain r/t myocardial ischemia and coronary spasm aeb substernal, aching, level 5 pain
what could show proof of myocardial ischemia? is the pain enough evidence to show that?
4. activity intolerance r/t imbalance between o2 supply and demand aeb verbal report of fatigue and weakness
5. deficient knowledge: performance of icd r/t lack of information aeb verbalized knowledge deficit
do you think i should kick one of the diagnoses out and use
powerlessness r/t chronic weakening illness aeb expression of having no control over situation or outcome
1. decreased cardiac output r/t cardiac arrhythmias aeb atrial fibrillation on ekg
does ineffective breathing take priority over decreased co (referring to abcs)?
2. ineffective breathing pattern r/t acute chest pain aeb dyspnea
is it ok to say r/t acute chest pain even though her pain has gone away?
3. acute chest pain r/t myocardial ischemia and coronary spasm aeb substernal, aching, level 5 pain
what could show proof of myocardial ischemia? is the pain enough evidence to show that?
do you think i should kick one of the diagnoses out and use
powerlessness r/t chronic weakening illness aeb expression of having no control over situation or outcome (i changed some of the wording)
see https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing student discussion forum) for information on how to write a care plan.
liverluv
6 Posts
I need some serious help!!! I've been working on my diagnosis for my process paper and am still struggling. My patient was admitted b/c her ICD was continually firing, she was experiencing SOB and angina unrelieved by nitro. The thing is, when I assessed her, she was going to be dc'd later that day, so her symptoms had all subsided. Her EKG showed a-fib w/ sinus bradycardia when I checked it. (Her PMD includes CHF, atherosclerosis, HTN, V-tach, A-fib, Dilated Cardiomyopathy, MI, Pulmonary Edema, amongst several others; her medical diagnosis was arrhythmias) This is what I have right now:
NURSING DIAGNOSES ***In priority order***
1. Decreased Cardiac Output r/t Cardiac Arrhythmias AEB Atrial Fibrillation on EKG
2. Ineffective Breathing pattern r/t Acute Chest Pain AEB Dyspnea
3. Acute Chest Pain r/t Atherosclerosis and Coronary Spasm AEB Substernal, Aching, Level 5 Pain
4. Activity Intolerance r/t Imbalance Between O2 Supply and Demand AEB Verbal Report of Fatigue and Weakness
5. Deficient Knowledge: Performance of ICD r/t Lack of Information AEB Verbalized Knowledge Deficit
Do I still keep all of the diagnoses even though she was not currently experiencing the symptoms? If so, does ineffective breathing pattern take priority over decreased cardiac output (bc of ABC's)? I also came up with
Powerlessness r/t CHF AEB expression of having no control over situation or outcome
also, but she came in b/c her ICD was excessively firing---not b/c of CHF--CHF is in her hx. though.
Should I get rid of the ineffective breathing and acute chest pain b/c she was not experiencing either when I assessed her?
Super confused and need some much appreciated help!! Any suggestions?