Need Help with the MOST Appropriate Nursing Diagnosis

[phatreecio]

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!

[Bortaz, MSN, RN]

Uh...wharglebsasrl.

Confusion is always nice. :)

[phatreecio]

Suesquatch said:

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

Thanks Suesquatch! You're definitely a great help! That's what I am thinking...

We formulated this diagnosis:

Acute pain related to fluid accumulation in the lungs as evidenced by patient's facial grimacing

OTH, one of us suggested this diagnosis, which I find questionable:

Ineffective breathing pattern related right lower lung consolidation as manifested by decreased lung expansion through pain felt on his right side, as evidenced by facial mask of pain

due to the ff. reasons:

1.) Diagnosis seems to be non-related with the patient's complaints

2.) The supporting symptoms (AMB, AEB) are too complicated leading to confusion

What do you think?!

[SuesquatchRN, BSN, RN]

For your as evidenced by, always use the patient's response to the pain scale - a/e/b patient rating pain as 6 on a 0/10 scale.

The problem with ineffective breathing pattern is that a lot of her ineffective pattern is due to pain, because it hurts to take a full breath, hence rapid resps.

The other problem is that we do not have enough evidence to support an ineffective breathing pattern. What are her O2 sats? Cap refill? Is she using accessory muscles to breathe? The only thing we KNOW about her breathing is that it is rapid. Crappy-sounding lungs just support crap in her lungs, nothing about her breathing pattern.

We don't know if it's ineffective airway clearance because we know nothing about whther her cough is productive.

We can't use impaired tissue perfusion because, again, we don't have enough evidence for that.

The only thing that you can really support with what you have is acute pain, and it's important for the reasons I stated.

Now, your instructors might have a different opinion, but I can't explain nursing instructors.

And the ineffective breathing pattern explanation used PAIN as the a/e/b.

:)

[phatreecio]

Any additional comments? Calling Daytonite.... I hope you can comment on this before we finalize our diagnosis...

Thanks!

[SuesquatchRN, BSN, RN]

I think she's online now so she should be by to clarify or correct any minute now.

[Daytonite, BSN, RN]

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.
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) XXX 
   • 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.
     • 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
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

Knowing the patient's medical diagnosis (pneumonia with consolidation) is only a help insofar as the information you can obtain about it in regard to its pathophysiology, signs/symptoms, usual tests ordered to diagnose and treatment it, 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 were given was:

• patient statement: "I have chest and flank pain which increases in intensity during coughing"
• temperature: 38.1˚c (100.6f)
• 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 which increases to 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 in left lower lung field

This is all evidence that will be supporting the use of any nursing diagnoses that you decide to use.

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.

Armed with your list of patient symptoms, which you could now call defining characteristics (nanda terminology) you go looking for appropriate nursing diagnoses with a nursing diagnosis reference to help you. This is step #2 of the nursing process.

Knowing the pathophysiology of the pneumonia is going to help you determine some of the etiologies of these diagnostic statements (the "Related to" part). 

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 suggestions 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. Ineffective airway clearance related to debris of inflammatory process cluttering airways as evidenced by dull sound percussed on the right lower lung field, diminished breath sounds auscultated in right lower lung field, and crackles auscultated in left lower lung field.
2. hyperthermia related to increased metabolic rate due to infectious invasion as evidenced by temperature of 38.1˚c (100.6f) and elevated heart rate of 102 bpm.
3. Acute pain related to swelling caused by inflammatory process in alveoli pressing on nerve endings as evidenced by patient's statement "I have chest and flank pain which increases in intensity during coughing", patient's description and intensity of stabbing chest pain and left lateral flank pain as being 5/10 (on a scale of 1 to 10 with 10 being the highest and 1 being the lowest) which increases to 6/10 when coughing, elevated blood pressure (110/90 mm hg), elevated heart rate (102 bpm) elevated respiratory rate (41 breaths/min), and facial mask of pain.
4. Deficient knowledge of medical condition, its treatment and discharge needs related to unfamiliarity with information resources as evidenced by verbalized questions of patient about his condition, medications and what he will be able to do after discharge. [I added this one because in the real nursing world it would be a part of the nursing care plan. discharge teaching includes: diet, allowed physical activity, medications they will need to take, treatments and tests they need to be doing after discharge, follow up appointments with doctors have been made and patient knows about them, referrals to any outside agencies or support groups have been made, and teaching materials and/or contact with outpatient professionals for continued care and teaching have been provided to the patient]
5. Risk for impaired gas exchange related to ventilation perfusion imbalance [the evidence that this may already exist just isn't there. there wasn't any documented abgs and evidence of hypoxia. that doesn't mean, however, that the patient isn't at risk for hypoxemia or an ineffective breathing pattern.]

I wanted to address your suggestions for nursing diagnoses:

Acute pain related to fluid accumulation in the lungs as evidenced by patient's facial grimacing

You are only part of the way there with the etiology (cause) of the pain on this. why does the accumulation of fluid in the lungs cause pain? and where is that fluid coming from? the answer is in the pathophysiology of infection and inflammation. as the byproducts of the inflammatory response build up and collect in the alveoli, that explains the signs and symptoms that come about (the consolidation on the cxr, the diminished or absent breath sounds, the crackles). the cardinal signs of inflammation (redness, heat, swelling and pain) are also occurring with internal inflammations and infections. you just can't visually observe the redness, heat and swelling which culminates in the pain like you can with a boo-boo on the skin. when swelling gets to be substantial it sets off the pain receptors.

If you look at the defining characteristics listed for the nursing diagnosis of acute pain in the nanda taxonomy you will see that your scenario gave you many other symptoms of the pain besides the facial grimacing.

Ineffective breathing pattern related right lower lung consolidation as manifested by decreased lung expansion through pain felt on his right side, as evidenced by facial mask of pain the etiology here, "right lower lung consolidation" is actually a symptom. therefore, it cannot be an etiology of the problem. ineffective breathing pattern is "inspiration and/or expiration that does not provide adequate ventilation ". it would be a pretty far stretch to say that a right lower lung consolidation is causing inadequate breathing when it isn't getting to the underlying cause of this consolidation. the defining characteristics (symptoms) for this diagnosis include assessments related to the patients breathing: alterations in depth of breathing, altered chest excursion, bradypnea, tachypnea, changes in inspiratory and expiratory pressures, changes in minute and vital capacity, dyspnea, nasal flaring, orthopnea, using pursed-lip breathing or using accessory muscles to breathe. if the patient has evidence of pain (facial mask of pain) then use a pain diagnosis.

[phatreecio]

Thank you so much guys and most especially you, Daytonite! You are a lifesaver!

[rhaychelle]

hello... can u please help me in doing my nursing diagnosis... my assessment are + dyspnea, pale, restlessness, RR 30... i need a diagnosis using PES problem, etiology, s/s...i already have this nursing diagnosis...

Impaired Gas Exchange related to altered oxygen-carrying capacity of blood AEB dyspnea and respirations 30/minute

i just dont know if the related factor is correct.... there is no given information about the patient's medical history or medical disease or medical condition so i had a hard time in doing the etiology... hope you can help me... thanks...:nuke: