Help with nursing diagnosis

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.
  • your instructors might have given it to you.
    
  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
    
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
    
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
    
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
    • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
      
    • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

[*]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:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

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.
   • [color=#3366ff]acute pain
     
   • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=40

[*]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. . .

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