Nursing diagnosis

  1. Hopefully someone can help guide me.

    I had a patient admitted for chest pain. Troponin was normal, wbc 15,000, platelets, h&h normal.

    history of idiopathic thrombocytopenia purpura, splenectomy and small intracranial hemorrhage.

    He complains about pain and burning upon voiding. No bladder distinction. Habitually withholds. Wbc 15,000

    can I have an at risk for infection (uti) if wbc are already elevated? Would this better be a readiness for enhanced learning r/t urinary elimination?

    Is is his chest pain more

    had chest pain BP, pulses, respiration, heart rate, lung expansion normal, no jvd. Troponin normal.

    complains of pedal edema after sitting all day and left knee swelling and pain.

    patient admitted after complaints of chest pain. Pain went away with

    Are these appropriate diagnosis?

    1) at risk for ineffective tissue perfusion r/t sedentary job aeb small intracranial hemorrhage, r/o dvt, and patient complaints of pedal edema and left knee swelling and pain after sedentary activity

    2) pain (chest pain) rule out mi aeb patient stating my chest hurt for an hour before coming to the er

    3) risk for caregiver roll strain aeb chest and stomach pain r/t lack of support caring for disabled wife and sole provider for household
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    Joined: Sep '16; Posts: 1

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  3. by   Guest12/13/16
    Do you have evidence that he is ready to learn? You can't just say that he has a problem and therefore he is ready to learn. There needs to be something from interacting with him that indicates that he is ready to learn.

    "can I have an at risk for infection (uti) if wbc are already elevated?" I would think not. Risk for indicates that there is no supporting data/ s/sx, which there is.

    "at risk for ineffective tissue perfusion r/t sedentary job aeb small intracranial hemorrhage." No, as I have already stated, risk diagnoses have no actual s/sx. They only have risk factors.

    "pain (chest pain) rule out mi aeb patient stating my chest hurt for an hour before coming to the er". No. You need a related to for an actual diagnosis before you have AEB. Actual diagnoses consist of P-E-S. Problem, (r/t) Etiology, (aeb) s/sx

    "risk for caregiver roll strain aeb chest and stomach pain r/t lack of support caring for disabled wife and sole provider for household" No. Again, it is P-E-S. Problem r/t Etiology aeb s/sx. And all of the latter must support the former. Chest pain (the s/sx) doesn't cause a lack of support (the etiology). The s/sx must be a s/sx of the etiology which must explain the problem.

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