Help with Nursing Diagnosis

Nursing Students Student Assist

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Can anyone tell me how to select the "R/T" with a diagnosis of "Decreased Cardiac Output"? I have identified the following defining characteristics in the nursing diagnosis manual that I guess would be the "AEB"?-- tachycardia (108 BPM); observable shortness of breath and variations in bp readings (162/88). I want to put "congestive heart failure" as the r/t but it's a medical diagnosis so I can't use it right?

The patient situation is as follows: 68 year old male who was admitted to your medical-surgical unit with a diagnosis of congestive heart failure. He reports Heart Rate (HR) 108 BPM, Blood Pressure (BP) 162/88, Temperature (T) 100.2 degrees orally, his respiratory rate (RR) is 24.

The patient is short of breath, has difficulty talking in full sentences, and can only walk short distances without becoming dizzy and winded. He appears to be very unsteady on his feet.

Thanks for your help!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

first of all what is chf?

heart failure, also known as congestive heart failure (chf), means the heart can't pump enough blood to meet the body's needs. over time, conditions such as narrowed arteries in the heart (coronary artery disease) or high blood pressure gradually leave the heart too weak or stiff to fill and pump efficiently.

heart failure (hf) often called congestive heart failure (chf) is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. heart failure is a global term for the physiological state in which cardiac output is insufficient in meeting the needs of the body and lungs. often termed "congestive heart failure" or chf, this is most commonly caused when cardiac output is low and the body becomes congested with fluid

http://en.wikipedia.org/wiki/heart_failurehere are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

  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)
  2. 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)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories https://allnurses.com/general-nursing...ns-286986.html

http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25166/6442619.cw/index.htm

always think abc's and with the complait of being dizzy i would think safety wuld be a concern as well. you may find these helpful...

http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25165/6442471.cw/content/index.htm

http://www.pterrywave.com/nursing/care plans/nursing care plans toc.aspx

http://www.pterrywave.com/nursing/care plans/12.aspx

http://www.pterrywave.com/nursing/care plans/13.aspx

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

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Maybe you could get by with saying decreased cardiac output r/t changes in the heart occurring secondary to congestive heart failure. You can list the medical diagnosis as being a secondary contributor, but you can't use it for your related to information.

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Diagnostic Statement: Decreased Cardiac Output

Related Factors: High BP, Altered Heart Rate and Rhythm, Increased Age

OR

Diagnostic Statement: Activity Tolerance

Related Factors: Generalized Weakness or Fatigue

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Thanks guys! This info has helped me out quite a bit- Esme, I really appreciate your answer and all the references. Thanks so much! This is my first assignment in nursing school and I feel completely confused but it's starting to make more sense with each day!

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R/t or in other words what is going on with the heart that is causing the decreased cardiac output.

As you have noted your evidence is HR 108 and BP 162/88.

Decreased Cardiac Output, r/t, altered HR and altered afterload, AEB HR 108 bpm and BP 162/88.

Afterload - the force against which a ventricle contracts that is contributed to by BP or vascular resistance

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i have said it before and i'll say it again: the words "related to" and "as evidenced by" should be removed from the nursing curriculum until senior year. if you want to learn to think like a nurse, you have to start using the language tools you come with, and ease into using the professional terms later.

nursing diagnoses are not to be found in some mythological chart with the first column being medical diagnoses and the second giving nursing ones, with the implication that nursing diagnoses are somehow derivative, secondary, or subordinate. nothing could be farther from the truth.

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

so. (i know my patient has) (this nursing diagnosis) (because he has ..... this presentation). (i know this because i can see/measure/discover....)

example: nursing diagnosis /my patient has self-neglect. this is because he has/related to inadequte personal hygiene, and nonadherence to health activities. i know this is true because he has/as evidenced by: cognitive impairment, a learning disability (specify), depression, and a medical diagnosis of capgras syndrome

does that make sense?

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To put it simply....(that's what always works best for me!)

r/t = WHY

WHY does the patient have decreased cardiac output?

Explain without using a medical dx

AEB = HOW do you know?

How do you know the patient has decreased cardiac output?

What is your evidence? = signs & symptoms the patient has that PROVE your nursing diagnosis is accurate

Remember -- always -- EBP Evidence Based Practice

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When I was in school one of our books to purchase was "Mosby's Sixth Edition Nursing Diagnosis Handbook". I was so consumed reading and studying for nursing tests by the time I got to looking at this book I was exhausted and found this book overwhelming and not user freindly. (WOW!!! WAS I WRONG) In hindsite I see how valuable this book is in learning how to write the parts of a nursing diagnosis.

You state you identified defining characteristics in the nursing diagnosis manual that you guess would be the AEB. In nursing school I overlooked a lot in my ND manual. Take a few minutes and familiarize yourself with your ND Manual. Skim the first few sections, the appendixes in the back and the index. If you have a good ND manual you should learn alot about how to write a ND in 15 minutes or less of getting familiar with your book.

The first 4 pages in my ND book explain how to write a nursing diagnosis and basically how to use the book. ( WOW!!! I wished I had read these pages while I was in nursing school.)

Section II of this ND book is, 112 pgs., of alphabetical order, medical diagnosis, and problems a nurse would need nursing diagnosis for, along with appropriate nursing diagnosis and r/t.

When you find yourself wanting to use the medical diagnosis as the r/t, look at the pathophysiology of the medical diagnosis and you will often find your r/t there.

Ex.

Arthritis-medical diagnosis

ND Chronic Pain r/t progression of joint deterioration

ND Activity Intolerance r/t chronic pain, fatigue, weakness

Ex.

COPD

ND Activity Intolerance r/t imbalance between oxygen supply and demand

ND Ineffective Airway Clearance r/t bronchoconstriction, increased mucus, ineffective cough, infection

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r/t bronchoconstriction, increased mucus, ineffective cough, infection

question i never thought to ask untill recently, can the dx have more than one r/t in the same d/x? nanda wise are we allowed to do that?

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of course. your nursing dx can have multlple causes, so you can list multiple causes. and you can list a medical dx as a cause, because, well, it can be the cause of the symptoms you cite as evidence for your nursing diagnosis.

have you actually looked in the nanda book? all of that is quite clear...and really will help you out with questions like this!

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I forget who posted this, or when, but I did get it from this site. Always helps me to refer back to this one.

The rules for constructing a 3-part nursing diagnostic statement are as follows. . .

  1. P. Stands for the problem. The problem is written as the nursing diagnosis. The words you use in writing the nursing diagnosis have already been determined for you by NANDA-I, the North American Nursing Diagnosis Association, International. You merely need to look them up in the most recent copy of one of their publications such as NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 or in any of the many currently printed nursing care plan or nursing diagnose reference books that are in publication containing this information. A nursing diagnosis is only a shortened label of the nursing problem which is more broadly defined and expressed in the definition contained in these references.
  2. E. Stands for the etiology. An etiology is the origin of cause of this identified nursing problem (P). It cannot be stated as a medical diagnosis. In the NANDA taxonomy you will find etiologies listed for many of the nursing diagnoses under the headings of "related factors". For physiological nursing problems (nursing diagnoses) you will need to know the pathophysiology of the disease process in order to determine the correct etiology, or related factor.
  3. S. Stands for the symptoms. Symptoms are the manifestations of the identified nursing problem (P). In the NANDA taxonomy you will find symptoms listed for many of the nursing diagnoses under the headings of "defining characteristics". Symptoms are proof that the problem exists. You will not have symptoms for "Risk for" diagnoses because these are not actual problems, but anticipated problems. Symptoms are determined by performing a thorough assessment of the patient and finding what is abnormal. Symptoms are abnormal findings.

In constructing the nursing diagnostic statement, these three elements are linked together in this way:

P related to E as evidenced by S

or

(P) R/T (E) AEB (S)

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