Help with my nursing diagnosis!!! Please!!

ImKosher · Nov 18, 2012

I would look at your r/t factors. Put them side by side and see which would most fit in line with your assessment and medical diagnosis. IMO it seems that the pt is 02 sat is sitting at 90% with low CO2 levels. Write out your r/t factors and see what would fit. I'm sure GRNTEA or ESME12 will sound in soon. Also, what a/e/b (es evident by) do you have for this pt?

eternallove · Nov 18, 2012

I am really having a hard time with this. We are told to use our labs and assessment to base our nursing diagnosis. So I've already stated his xray showed a pneumothorax, Chem 7 was low CO2 and low Calcium. Patient had irregular heart beat, shortness of breath and respiration rate 24/...the eab would be dyspnea and diminished breath sounds ...pulse was 101 so maybe tachycardia also?

Esme12, ASN, BSN, RN · Nov 18, 2012

Welcome to AN! The largest online nursing community!

Are you sure your edema is from decreased cardiac output? Are you sure he has a decreased cardiac output that it is from obesity? Why would the VAP(ventilator assisted pneumonia) cause hypotension? There is not enough information here to make a good diagnosis really. I think you are falling into the pitfall that catches students......finding a diagnosis and fitting the patient into it.

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:) what care plan book do you use.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

I am willking to help ........So tell me about your patient.......What are the labs? What are the vitals? What are the ABG's? What is YOUR assessment of the patient? Are the febrile? What do the complain of????

What is this patients story......TELL ME ABOUT YOUR PATIENT.

What care plan book do you use? Having a good cage plan book and/or a nursing diagnosis book is essential to do care plans. Nursing Diagnoses 2012 - 2014.pdf‎ (35.7 KB, 3833 views)

Here are some brain sheets made by another contributor Daytonite (RIP) for you next care plan.

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

eternallove · Nov 18, 2012

OKay here is what I've got...the patients x-ray showed a large R pneumothorax- Patients labs showed low CO2 and Calcium levels, now assessment- Pt's vitals were Pulse 101, R 24, 2 Sat 90%, patient was in pain-patient had diminished lung sounds bilaterally R side,- pale/no edema/S1 S2 sounds w/ A-Fib/ Brisk capillary refill...Here is what I came up with for my main diagnosis

Impaired Gas Exchange r/t air in intrapleural space of lungs, decreased functional lung tissue AEB diminished breath sounds R bilaterally and tachypnea (24)

Does that seem logical? Where should I go from here with other diagnosis?

eternallove · Nov 18, 2012

OKay here is where I am at..Let me know what you think, Please and Thank you

#1-Impaired Gas Exchange R/T air in intrapleural space of lungs, decreased functional lung tissue AEB diminished breath sounds R lobe bilaterally and tachypnea (24)

#2-Ineffective tissue perfusion R/T compromised blood flow AEB atrial fibrillation

and for my third/ should I do pain due to his pain where chest tube inserted/ or risk for infection?

Any advice is much appreciated!! THank you

psu_213, BSN, RN · Nov 18, 2012

#2-Ineffective tissue perfusion R/T compromised blood flow AEB atrial fibrillation

Remember, your AEB is the symptoms that the pt is experiencing as a result of their problem/diagnosis...in other words, your AEB is the what tells you that the pt is having this particular problem. The AEB is not what is causing the problem. So the question then becomes: is the A fib a symptom of ineffective tissue perfusion or a possible cause of it? If it is the cause, then it would be the etiology (the R/T)...you would have to word it so that it is not a medical diagnosis.

So what symptoms would indicate to you that this person has ineffective tissue perfusion? In other words, how can you tell that not enough blood is flowing to the tissues? How would you tell if his kidneys are not being adequately perfused? His extremities? etc...

Esme12, ASN, BSN, RN · Nov 18, 2012

OKay here is what I've got...the patients x-ray showed a large R pneumothorax- Patients labs showed low CO2 and Calcium levels, now assessment- Pt's vitals were Pulse 101, R 24, 2 Sat 90%, patient was in pain-patient had diminished lung sounds bilaterally R side,- pale/no edema/S1 S2 sounds w/ A-Fib/ Brisk capillary refill...Here is what I came up with for my main diagnosis
Impaired Gas Exchange r/t air in intrapleural space of lungs, decreased functional lung tissue AEB diminished breath sounds R bilaterally and tachypnea (24)
Does that seem logical? Where should I go from here with other diagnosis?

What were the other labs? What was the H/H, WBC's, lytes, Bun, Creat, Where there ABG's done? How old is this patient? You said this patient on the day of your assessment the chest tube had been removed and was diagnosed with pneumonia........was this patients pneumothorax resolved?

When was the chest tube removed? Was a CXR performed post chest tube removal? What was their main complaint? You state the patient was diagnosed with pneumonia.......so is their impaired gas exchange due to air in the pleural space? or is it caused by the pneumonia? Was this patient febrile? Are they able to perform their ADL's?

Ok.....your patient is SOB. Are they on 02? You of course consider your ABC's and Malows for your priority diagnoses.

SO..airway and breathing. Your patient had (past tense?) a collapsed lung and they are SOB. A subsequent CXR shows pneumonia. First you need to know what a pneumothorax is....what are the complications? What is pneumonia?

That means........Your patient probably has impaired gas exchange R/T the pneumonia (collection of mucous in airway/inflammation of airways and alveoli/fluid filled alveoli/ventilation perfusion mismatch [bacterial pneumonia]/lung consolidation with decreased surface area available for gas exchange)......AEB what? Your supporting evidence is tachypnea, tachycardia and 02 Sat of 90%.....right?

The next thing you mention is that this patient c/o pain. What kind of pain? Where is the pain? Where on the pain scale is this patients pain? What is causing their pain?

Acute Pain R/T......by what? AEB....what? the patients complaint...the patient states. Look to you nursing diagnosis book for how they fit your patient

Hyperthermia if they have a fever

Ineffective Airway clearance if they have a productive cough

Activity intolerance because they are SOB

You need to look in your nursing care plan book for the taxonomy that applies to these diagnosis what they definitions are and how they fit your patient by your supporting evidence. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition ......yes even after 35 year of being a nurse I use care plan books. It's what you need to use especially when you are learning. In the books they have the NANDA definition, defining characteristics, related factors, suggested outcomes, patient outcomes, AND nursing interventions.

What book do you have?

eternallove · Nov 18, 2012

I have Prentice Hall Nursing Diagnosis Handbook, 8th edition, Judith M. Wilkerson

The patient had no other labs...We did our assessment with the chest tube in place, and it was not until we were dismissed our teacher told us the patients tube had been taken out and was now diagnosed with Pneumonia, so i'm assuming that we are to do our diagnosis based on what we saw and were told at that time based on the labs we saw...I am a first semester nursing student so I'm sorry if I don't completely understand. It is very frustrating to do this when you aren't really taught a whole lot on the subject. I know she made hints about his atrial fib. oh, and he did wear compression boots but everything else is what I've already listed..And he is on 3 Liters of O ...Thanks

ImKosher · Nov 18, 2012

Like Esme12 said use your diagnosis book to help guide you in finding out the materials and information you need to come up with a strong care plan. I would recommend getting the Ackley or Nanda as a second source if you don't feel confident with your book.

In regards to your care plan, I would e-mail your teacher and ask if you are able to make a care plan based on your assessment with the chest tube placed, because that was in place during your assessment. I don't believe you can base your plan of care with "stated" removal.

A question for Esme12 what would you do in this instance of the pt condition changed after your initial assessment without another assessment on changes as a student like as such being told during post conference?

Esme12, ASN, BSN, RN · Nov 18, 2012

Well....now that I have the story......I would do an initial care plan in the patient with the chest tube and on pneumothorax and add the information about the pneumonia. It would be completely up to the CI and what the focus lecture is and what she is wanting the students to focus on. I always tried to find the patient with pertinent diagnosis to their present...or past lectures. What this CI requires is up to her.

Immediately after a chest tube is removed you still frequently assess lung sounds and assess for air leak from the chest tube insertion site. I agree with ImKosher that you need to clarify with your instructor on what her expectations are. That the patient has AFib I have no information that the patient has any of the complications from afib....but the same process applies. What is AFib? What causes afib? What are the complications of Afib? Is this patient on anti-coagulants? Do they have evidence of any blood clots to the lings or legs?or a DVT? (deep vein thrombus) They are AT RISK forIneffective peripheral tissue Perfusion.

OP it's ok if you do not understand....Read what I posted earlier it will help you a lot. But this pateint remains hypoxic and in pain.

Llawver · Nov 20, 2012

Look up respirtory alkalosis. Alot of the symptoms you are describing relate to that. If you just need one diagnosis I would go with impaired gas exchange r/t pneumothorax e/b increased respirations and hypercapnia. As far as tissue perfusion I would not go with that because his 02 sats are to be expected with his condition. A good way to know if tissue perfusion is inadequate is to check capillary refill and radial and pedal pulse. If the pulses are thready and weak it's a good indicator that not enough blood is reaching the extremities. They will often have tachycardia because the heart is trying to compensate and pump blood faster.