Influencing stimuli for abnormal symptoms

[NN2BVE]

For our care plans we need to write up assessment data and for each abnormal assessment we have to come up with the influencing stimuli for that ( that would be the R/T or the etiology of the abnormal finding as how I understand it).

My patient has a long history of COPD and recent diagnosis of CHF. The admitting diagnosis is pneumonia.. When presenting in the ER was complaining of chest pain. I'm having trouble to decide what would be influencing stimuli for the symptom (chest pain). I have trouble choosing between hypoxia, infection in the lungs, COPD and CHF. There is a lot going on in this patient. Can you please help.

[EricJRN, MSN, RN]

What other assessment data do you have to guide that decision in this patient? That's a big part of the process.

[NN2BVE]

thank you for helping me out here.

this is what i got:

hr 140; bp 118/58; skin warm and dry; (3) peripheral edema +1; (5) peripheral pulse weak;

rr 28, oxygen sat 88 % wheezes in both sides of lungs ;(6) no sputum produced;

bnp 276

troponin 0.69

admitting diagnosis:

pneumonia, atrial fibrillation with rapid ventricular response and chf class iii

this is my only second week on the clinicals so i hope i look at the right data. is there any other specific information that i'm not looking at but should? if so could you please guide me? thank you so much for your time and help.

[Daytonite, BSN, RN]

assessment involves more than just doing a physical exam or interview of the patient. it includes:

• 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. to do that you can use:
  
  • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
    

you need to read about copd and chf. these are both conditions that do not just develop suddenly. a lot of pathology within the body goes on for years for these two medical conditions to develop. what are they? copd is a broad term for a handful of obstructive lung diseases of which emphysema and obstructive bronchitis belong. which one does this patient have, or is likely to have? what clues were reveal in the history and physical exam written by the physician? chf has to do with the heart not being able to do its work. the heart does not fail in doing its job overnight. what kind of cardiac medications is this patient on that might help reveal what is wrong and being corrected with his heart?

pain is usually caused because of something that is injuring or stimulating the pain receptors in the area where the pain is being perceived.