Need Help with the MOST Appropriate Nursing Diagnosis

Updated | Posted
by phatreecio (New) New

Guys, Hello, I'm completely confused on what we need to do about our nursing diagnosis.

See, we have a thesis wherein, as student nurses, we're required to defend our case.

Medical Diagnosis: Pneumonia with consolidation

This is the problem, based on our assessment, here's the patient's data:

Subjective: Patient stated "I have chest and flank pain which increases in intensity during coughing"

Objective:

  • Vital signs: Temperature: 38.1˚C
    PR:102 bpm
    RR: 41 breaths/min
    BP=110/90 mm Hg
  • Stabbing chest pain and left lateral flank pain with a pain scale of 5/10 and pain is increased to a scale of 6/10 when coughing (Pain scale with 10 being the highest and 1 being the lowest)
  • Facial mask of pain
  • Dull sound on the right lower lung field upon percussion
  • Diminished breath sounds on right lower lung field upon auscultation
  •  (+) crackles on left lower lung field

We're debating as whether to use:

Acute Pain

or Ineffective Breathing Pattern

so that we can formulate an

effective care plan...

Please Help and reply asap!

Your comments are greatly appreciated:

Thank You so Much!

phatreecio

1 Article; 8 Posts

My apologies,

Please move this thread to the:

Nursing Student Assistance Forums

Thanks!

Bortaz, MSN, RN

Specializes in CDI Supervisor; Formerly NICU. Has 13 years experience. 1 Article; 2,628 Posts

A

B

C

In that order. Airway, breathing, circulation.

That's your priority.

Bortaz, MSN, RN

Specializes in CDI Supervisor; Formerly NICU. Has 13 years experience. 1 Article; 2,628 Posts

Really? Do you mind explaining why?

I was thinking ABCs, and:

RR: 41 breaths/min

*Dull sound on the right lower lung field upon percussion

* Diminished breath sounds on right lower lung field upon auscultation

* (+) crackles on left lower lung field

and:

Medical Diagnosis: Pneumonia with consolidation

mybrowneyedgirl, BSN, RN

Specializes in Emergency Room. 410 Posts

I am a student as well and have never done a care plan but I thought the ABCs were most important. I would say impaired breathing related to ....

good luck! There is a careplan help section here that might have some archives you can search related to this.

The user Daytonite is always an amazing source of help with careplan thinking.

Googled this as well from a sample pneumonia care plan, but it does not detail all the symptoms of your client. Thought it might help guide you.

Assessment: The patient has SOB (Shortness of Breath) on exertion.

Diagnosis: Altered Respiratory Status related to pneumonia

Plan: Administer 02 and check vital signs every 4 hours.

Implementation: The patient has been maintained on 2L NC (2 liters via nasal canula). Vital signs have been checked every four hours and have remained WNL (within normal limits).

Evaluation: Pt is able to get out of bed and sit in his chair without feeling SOB.

Mind you, this is only one aspect of his plan of care. A patient with pneumonia will probably have numerous interventions while he is in the hospital, and so you could include each of these interventions within your care plan. This may seem like a lot of work if you are a nursing student, and many nights you will find yourself staying up and writing these things before you show up for your 7AM clinical. (Hey – I didn’t invent the system- I’m just trying to help you get through it!) If you break it down into simple steps, it becomes a much easier process.

phatreecio

1 Article; 8 Posts

mybrowneyedgirl said:
I am a student as well and have never done a care plan but I thought the ABCs were most important. I would say impaired breathing related to ....

good luck! There is a Care Plan help section here that might have some archives you can search related to this.

The user Daytonite is always an amazing source of help with Care Plan thinking.

Guys,

Thanks for your response! That's what we're confused of. Patient is complaining about pain subjectively. But, based on our assessment, he has the above signs and symptoms.

Pretty confused whether to focus on what the patient is complaining at that moment or focus on what our patient showed during assessment.

:banghead:

Bortaz, MSN, RN

Specializes in CDI Supervisor; Formerly NICU. Has 13 years experience. 1 Article; 2,628 Posts

If he stops breathing, it won't matter how much pain he's in. IMHO.

But, I don't know anything, really...or, at least I sometimes feel like I don't!

Go with the Nurse over the students, though.

ABC's are definitely most important, but remember, pain is "the fifth vital sign."

Reluctance to cough because it hurts will interfere with her willingness to clear her airway through deep breathing and coughing. It will interfere, as well, with her mobility because she won't want to move, which will lead to increased congestion. She will not want to use the incentive spirometer.

Pain is a big part of why her respirations are so rapid.

The interventions for ineffective breathing pattern are less immediately effective than treating pain.

Does my reasoning make a little more sense to you now?

mybrowneyedgirl said:

Diagnosis: Altered Respiratory Status related to pneumonia

Just a note, you can't use pneumonia as the r/t as that is a medical diagnosis.

Bortaz, MSN, RN

Specializes in CDI Supervisor; Formerly NICU. Has 13 years experience. 1 Article; 2,628 Posts

Yep, and I appreciate it!

surferwahine45

Specializes in Trauma, Neuro, Surgical ICU,. 3 Posts

Always start with your ABC's! So Impaired breathing r/t... Also make sure you break your care plan down to the cellular level. Good luck! Remember care plans don't last forever!!:yeah: