Need Help with Nursing Diagnosis

[pinkerton]

I am a new nursing student and have been struggling to come up with a nursing diagnosis related to respiratory & cardio on this scenario. Man with diabetes 1, bs high (255), HTN, overweight, vitals normal, recent surgery on hand 1" incision with some redness & mild swelling. Nocturia 1 X nightly, 3-4 X week. Lungs CTA, cap refill

I am thinking he is at risk for a pulmonary embolism, but I don't think I can use that as a risk for diagnosis because it is a medical condition.

I also wanted to use risk for complication of decreased cardiac output r/t hypertension, but also a medical diagnosis. The bp was 120/69 probably under control due to meds.

Once I figure out what I can use I still need my goal and interventions.

Appreciate any thoughts.

We use a Carpenito book for diagnosis, but are allowed to use others. I don't know if my book is any good, but would like to get another one. Any suggestions on the most helpful to new students?

[chicklet74]

I use the Nursing Diagnosis Handbook - 8th edition by Betty Ackley. It's a great help with deriving Nursing diagnosis from the medical diagnosis. I'd pick up a used copy. I use mine almost every day - it practically writes the care plan for you. Try this link -

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/index.php. If you can get to it, all you have to do is type in your medical diagnosis and it will give you a list of nursing diagnosis that coincide. You can just pick the ones that apply to your patient. I'm not sure if you need the textbook to gain access to this site, but give it a try. Definately, I would use Imbalanced nutrition - more than body requirements as well as some others. Decreased cardiac output is listed in my book as a nursing diagnosis, but I'm not really seeing where it applies here - I could be wrong. There are likely a few related to that high glucose as well.

Good luck!

[pinkerton]

Thanks for your help.

I am trying to relate the diagnosis to cardio and I think hypertension would decrease cardiac output so that is why I chose that one. I am just stumped as how to relate to cardio.

I thought about using the imbalanced Nutrition more than body requirements, but I don't know if that could be used as a cardio diagnosis. My interventions are weight related, sodium related, and monitor bp.

[melmarie23, MSN, RN]

make a diagnosis based on your assessment. The patient is currently hyperglycemic, so I'd focus on that first

possible diagnoses:

risk for unstable blood glucose AEB _______________(bs reading of 255, inactivity, lack of diabetes management, lack of medication management, physical health status, ...any of these might fit what is going on with your patient)

disturbed sensory perception r/t ineffective tissue perfusion (question: where did you test his cap. refill?)

ineffective tissue perfusion: peripheral r/t impaired arterial circulation (how were his pedal pulses?)

imbalanced nutrition: less than body requirements r/t inability to use glucose

then you can use risk for infection, risk for injury, risk for impaired skin integrity, etc, etc.

Ditto the above poster on getting a Nursing Diagnosis handbook. I use Guide To Nursing Diagnosis, 2nd edition, by Ladwig and Ackley.

[melmarie23, MSN, RN]

Thanks for your help.

I am trying to relate the diagnosis to cardio and I think hypertension would decrease cardiac output so that is why I chose that one. I am just stumped as how to relate to cardio.

I thought about using the imbalanced Nutrition more than body requirements, but I don't know if that could be used as a cardio diagnosis. My interventions are weight related, sodium related, and monitor bp.

connect it to cardio if he is presenting with a cardiac issue, such as high blood pressure, poor cap refill, brady/tachycardica etc. You said his vitals were normal (which I assume includes blood pressure and HR), as was his cap refill, so like I said with my previous post, I'd just concentrate my diagnosis on what is currently wrong with the patient, not hypotheticals. Does that make sense?

[Daytonite, BSN, RN]

a diagnosis is always based on the evidence (abnormal assessment data) you have before you.

• high blood sugar of 255
  
• 1" incision on hand with some redness & mild swelling (symptoms of the inflammatory response which occurs before and along with infection are redness, heat, swelling, and pain)
  
• elevated wbc count (elevated wbc is evidence that the body is engaged in the inflammatory response and quite possibly an infection)
  

each of these are evidence of a nursing problem.

1. imbalanced nutrition: more than body requirements
   
2. impaired tissue integrity
   
3. risk for infection
   

your goals and nursing interventions will be based upon that abnormal assessment data that goes into determining the diagnoses. quite simply, your goals will be what you predict will happen if your interventions are carried out. that abnormal data is the foundation of the entire care plan. read the beginning pages of your carpenito book again. she's very good about explaining all that.

[pinkerton]

Thanks so much for your responses. They are very helpful.

The cap refills were taken on R fingers and toes.

I am still working on assessments that must be related to cardiovascular & respiratory and this guys issues don't really have a nursing diagnosis for those unless I use a wellness diagnosis.

How about if I change the scenerio. What if he smoked 1 pack cigarettes a day for the last 30 years, works on a road crew and breaths in car fumes often and his BP is 149/88. What nursing diagnosis would you use on this man that relate to cardio/resp. systems?

Thanks again

[Daytonite, BSN, RN]

Decreased Cardiac Output.

[pinkerton]

Thanks Daytonite,

I really appreciate your help. I am still confused (remember I am new at this) I thought that hypertension and and a bp of 149/88 would increase cardiac output. What am I missing here?