Help with nursing diagnosis

Published

I'm working on a nursing process paper and am stuck.....I need 5 nursing diagnosis for this patient in priority order with R/T and AEB. Brief on pt: 69 y.o. admitted for atypical chest pain, complaining on right-sided chest pain, had a non-ST elevated MI last month, hx includes: GERD, HTN, Hypothyroidism, and osteoarthritis. and the admitting doc thinks her issue is GI related and says it is visceral chest pain not felt to be of cardiac etiology. She has been having some heartburn and has a atypical dysphagia to solids and liquids. She had a esophagogastroduodenoscopy and it showed a stricture so they dilated it. Her pain is a 4/10 and described as an aching feeling. It is not brought on by anything, it comes and goes. Vital signs are stable, she is in sinus rythm, All tests (CBC, cholestoral, troponin, liver function, EKG, chest xray, RUQ ultrasound, etc) are all normal...... Obviously my first diagnosis would be Acute Pain R/T patient complaint of pain, a 4 on a 0-10 scale AEB patient pressing on chest But I need 4 other ones...........any help would be much appreciated?!

Up Vote Up Vote ×

Try to think about this as if it were you in the situation. How would you be feeling? What would you be able to do, what wouldn't you be able to do? I usually look through the condensed list of Nursing DX and see if any look like they apply, then look up that specific DX and see if any of the characteristics match. Good luck

Up Vote Up Vote ×
Specializes in Emergency Room.

Trouble with swallowing foods and liquids - you could risk dehydration or poor nutrition with that symptom.

Mind you this thought is coming from a first year nursing student so I might be looking at this all wrong.

Good luck.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

care planning is about determining the patient's nursing problems, prioritizing them, and then developing solutions to treat them. determination of the nursing problems is done by performing a thorough assessment of the patient to see what abnormal data shakes out. prioritization of those resulting problems is usually carried out by some classification system with maslow's hierarchy of needs being a commonly used one although your nursing instructors may have given you other directions. solutions to treat nursing problems are the nursing interventions you are learning about in classes and from your nursing textbooks.

the nursing process is the tool that we have been given to help us problem solve and it is easily adapted to care planning and should be used even if care plan books are being consulted:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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)

  • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

knowing the patient's medical diagnoses and procedures that were done (atypical chest pain, atypical dysphagia to solids and liquids, esophagogastroduodenoscopy that showed a stricture that was dilated, non-st elevated mi last month, gerd, htn, hypothyroidism, osteoarthritis) will only help insofar as the information you can obtain about them in regard to their pathophysiology, signs/symptoms, usual tests ordered to diagnose and treat, normal medical treatment, knowing any medical procedures that you anticipate might be performed on the patient, their expected consequences during the healing phase, and potential complications. this data is needed to double check that you didn't overlook something or miss the important of something in your own assessing that you did. beyond that, you depend on the data you have from the patient themself because, and keep this in focus, the care plan is about treating the patient's nursing problems.

the abnormal data about the patient that you have is:

  • right-sided chest pain is a 4/10 and described as an aching feeling, not brought on by anything, it comes and goes
  • having some heartburn

i think it essential to look up the signs, symptoms and complications of atypical chest pain, atypical dysphagia, esophagogastroduodenoscopy, a stricture of the esophagus, a non-st elevated mi, gerd, htn, hypothyroidism, and osteoarthritis for the very simple reason that you may have missed seeing symptoms of these conditions when you did your assessment of this patient. it's not too late to retrace your steps to find any lost assessment information at this time. the medications she might be taking are also a tip off to possible problems she might and could be having as well. i'm concerned about this lady's recent mi. my first inclination was to go with a nursing diagnosis of decreased cardiac output because of the decreased perfusion situation that she now has going on in her heart, but you have no evidence of it. i'm not being mean here, but it has to exist. this lady is most likely a ticking time bomb of cardiac atherosclerosis with the next mi just waiting around the corner. does she have a history of drinking? what's going on with this osteoarthritis and what is her ability to move around like? was she ringing for help to get out of bed or walk? dress?

esophageal stenosis is a reduction of diameter of the esophagus. symptoms & signs can include sialorrhea, dysphagia and regurgitation at beginning at transition to solid diet. the underlying cause of any pain can be due to acid erosions and/or swelling caused by an inflammatory process that is occurring. treatment is esophageal dilatation.

http://www.csmc.edu/5862.html

a word about nursing diagnoses: officially (per nanda--the north american nursing diagnosis association) there are currently 188 of them that they have researched and developed definitions, defining characteristics (signs and symptoms) and related factors (etiologies) for. this is called the taxonomy. and, oh, how helpful it is when you are new at nursing diagnosis. just about every currently printed care plan book today includes the taxonomy that applies to the nursing diagnosis being addressed. for sources of the printed taxonomy see where i listed them above. every nursing diagnosis has a set of defining characteristics (signs and symptoms, evidence) of which your patient must have one or more in order to support the existence of that particular nursing problem in the patient.

the formation of the 3-part nursing diagnostic statement (pes) is discussed on this sticky thread in the general nursing student discussion forum:

using your list of patient symptoms and my copy of nanda-i nursing diagnoses: definitions & classification 2007-2008 i will give you my suggestion for the diagnosing of this patient along with links to nursing diagnosis web pages on the ackley/ladwig and/or gulanick/myers care plan constructor web sites if they are available where you can see the nanda taxonomy for those diagnoses as well as outcome and intervention suggestions. i will also list them in priority according to maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs).

  1. acute pain r/t esophageal inflammation aeb patient complaints of heartburn; and a right-sided aching chest pain that comes and goes, is not brought on by anything, and has an intensity of 4/10.

[*]readiness for enhanced nutrition r/t willingness to improve health aeb statements of a positive attitude to make healthy nutrition and food choices to incorporate into her diet.

diagnoses are based on symptoms and potential complications. i would go back through the medical diagnoses and medications the patient is getting as well as what you observed about the patient and the way she performed her adls to see if there is something you may have overlooked.

about your choice of acute pain r/t patient complaint of pain, a 4 on a 0-10 scale aeb patient pressing on chest. . .

the "related to" part of the diagnostic statement is always the cause, or etiology, of the problem--in this case acute pain. the nanda taxonomy gives us assistance here. it lists the etiologies for acute pain. there is only one listing

  • injury agents (biological, chemical, p0hysical, psychological)

"patient complaint of pain, a 4 on a 0-10 scale" is actually a symptom and not the cause of the pain. to find the cause, you have to figure out what the pathophysiology is that is going on. this is why knowing the medical diagnosis is important. with a history of gerd and complaints of heartburn there is most likely acid irritation going on that is either setting off the inflammatory response which would be causing swelling of those internal tissues. the swelling sets off the pain nerve receptors or the acid just sets off the pain nerve receptors directly. it's hard to be sure, but one of them is the answer.

you didn't mention that the patient pressing on her chest causing pain was one of your assessment items. if this is true then it needs to be an added symptom to my
acute pain
diagnosis.

Up Vote Up Vote ×
+ Join the Discussion