help needed with my first nursing diagnosis

[mydestinyy]

i have come up with the first diagnosis as CHRONIC PAIN related to heart disease as evidenced by patient complaining of a never ending dull pain in the chest wall.

second diagnosis is HYPERTENSION related to shortness of breath evidenced by patient irregular movement of the chest wall

:confused:

please correct me and yes this is my first time so..i seriously need some help..

[Mike R, ADN, BSN, RN]

Check out this link for tons of resources about Nursing D(x)'s.

https://allnurses.com/nursing-student-assistance/check-here-first-272271.html

Your R/T's cannot be a medical D(x). So heart disease isn't what you want to use. Think of the most basic etiologic explanation you can come up with that describes exactly what is causing the pain. Maybe, "R/T decreased oxygen perfusion to heart muscle" or something along those lines.

Also, your AEB's need to be measurable and quantitative. How does one actually measure "never ending pain in chest wall"? Consider: "patient states chest pain is continuous at 8 on the 0-10 pain scale".

The second NANDA doesn't work well either. Is HTN really related to SOB? If I came up to you and said " this guy's chest is moving funny, he may have HTN." Would you believe it? Only on what you've stated, a better NANDA would be to try Ineffective breathing pattern.

[mydestinyy]

hmmm i didnt have a good feeling of it ..well thank you so very much for your help..i will work on it and shall post it :)

[mydestinyy]

case study:

"85 year old female with a history of valvular heart disease, hypertension,dementia,osteoporosis,pneumonia,left knee surgery."

my CI wanted me to choose one primary and one secondary dx..anyways i went ahead and just tried to figure out as many as i can..please help( i was thinking of choosing chronic pain as primary and ineffective breathing as the secondary dx)

chronic pain r/t decrease in oxygenation of heart muscle as evidenced by patient stating of everlasting pain

impaired mobility related to pain and discomfort in the left knee aeb limited range of motion

chronic pain r/t inflammation and swelling of the left knee aeb patient guarding her knee.

fatigue r/t being bed ridden for a month evidenced by inability and weakness to sit up straight .

ineffective breathing pattern r/t inflammation of lungs as evidenced by irregular respiratory chest movement.

[Mike R, ADN, BSN, RN]

case study:

"85 year old female with a history of valvular heart disease, hypertension,dementia,osteoporosis,pneumonia,left knee surgery."

my CI wanted me to choose one primary and one secondary dx..anyways i went ahead and just tried to figure out as many as i can..please help( i was thinking of choosing chronic pain as primary and ineffective breathing as the secondary dx)

chronic pain r/t decrease in oxygenation of heart muscle as evidenced by patient stating of everlasting pain

impaired mobility related to pain and discomfort in the left knee aeb limited range of motion

chronic pain r/t inflammation and swelling of the left knee aeb patient guarding her knee.

fatigue r/t being bed ridden for a month evidenced by inability and weakness to sit up straight .

ineffective breathing pattern r/t inflammation of lungs as evidenced by irregular respiratory chest movement.

I noticed you forgot about measurable AEB's. Don't forget that you need objective, subjective and measurable data.

When choosing NANDAs, always go with ABC's first. Since you have pneumonia up there, I might go with complications from that, like impaired gas exchange. Next I might go with neuro status. Dimensia is listed so I might go with chronic confusion.

I'll give you an example to play with (this won't specifically apply to your patient but it'll get you thinking): Constipation R/T decreased peristalsis secondary to anesthesia AEB hypoactive bowel sounds, no BM x3 days, abdomen distended and tender.

[mydestinyy]

thank you for your help..i will work on dx some more and will get back..thanks again

[Suethestudent]

Don't use everlasting pain as it is not a commonly used term ... try continuous pain.

[mydestinyy]

first dx : impaired gas exchange related alteration of airflow to the lungs as evidenced by irregular movement of the chest, shortness of breath and irritability.

second dx: decreased cardiac output r/t decrease in the oxygenation of the cardiac muscle as evidenced by variations in ecg , heart rate,abnormal abg,cardiac output, anxiety, restlessness and dizziness.

third dx: activity intolerance r/t continuous pain on the left knee aeb swelling of the left knee and patient rating pain to 9 over 10.

i just need two but went ahead n did a third one just to make sure i get the hang of it..

please review this..

thanks

[mydestinyy]

chronic confusion related to dementia aeb impaired long term memory and no change in the level of consciousness.

disturbed body image related to scars on left knee aeb patient stating " i hate this scar, it is so ugly."

decreased cardiac output r/t changes in the heart rate, rythm and conduction aeb patient complaint of chest pain, abnormal abg findings, arrythmias and alterations in ecg.

ineffective breathing pattern r/t continuous chest pain aeb flaring of nostrils, patient complaint "my chest hurts so bad, can hardly breath", anxiety and restricted movement.

risk for constipation r/t immobility and pain in the chest aeb patient stating fear of pain getting worse on moving and depression.

impaired physical mobility r/t pain, weakness on left knee joint aeb surgery done on the left knee and patient complaint of " excruciating pain" on the left knee.

[Rednights]

Looks fine ...

[mydestinyy]

thanks..will definitely work some more on dx..:)

[Mike R, ADN, BSN, RN]

first dx : impaired gas exchange related alteration of airflow to the lungs as evidenced by irregular movement of the chest, shortness of breath and irritability

you're on the right track. know that eventually, you'll need a goal with specific numbers/values/conditions that you will relate directly to your nanda. so, given what you have, your goal will read: "patient will not have impaired gas exchange within x hours aeb no irregular movement of the chest, no sob and no irritability.

what is "irregular movement"? what is "irritability"? these two conditions can be interpreted very differently from person to person. so these aren't strong aeb's to use.

there are much better aeb's to use for impaired gas exchange like: o2 sats, specific advantigious breath sounds and location, sob upon ambulation of x feet. see where i'm going?