Nsg Diagnosis in CPNE study guide

[shawnnarae]

I am going through the study guide doing all the practice questions and sample PCS things they have in there and all its doing is making me feel stupid. I think I may be lost on this nursing diagnosis stuff. I always end up thinking of a different one and not the one excelsior thinks is the best... or whatever. Anyway, I am just really frustrated and needed to get it out before I freak out.

:)

[SuesquatchRN, BSN, RN]

Shawnna, use the Kardex. And read the thread on "I took the Excelsior CPBE Workshop." It's a sticky. It has some info on how to choose one.

Nothing fanct. Maslow. Breathing, ADL's, pain.

[shawnnarae]

Thank you. :-)

During the CPNE, do they expect you to pick the nursing dx that they think should be there, or if you give a good rationale as to why you picked the one you did, will that be accepted? Sorry I ask a million questions, I am getting so flustered and im not testing for 2 months.

[SuesquatchRN, BSN, RN]

First, calm down.

Say you have someone on morphine. Choose "Acute pain." There is evidence for that. You don't get morphine for something trivial. "related to - etiology." NOTHING medical. tissue trauma, etc. "as evidenced by" - use your pain scale. "Patient rates pain at 7 on 0-10 scale."

You need two nursing interventions, one of which has to be measurable DURING THE PCS. So intervention one will be, "Have the RN administer pain medication." Your second could be, "Offer a back rub, wash-up, distraction."

Now, you need an outcome. "Patient will rate pain at 5 on a 0-10 scale"

RATIONALE: "Pain caused decreased tissue prefusion and impedes healing."

Help?

[shawnnarae]

Thank you very much, that does help. :-)

One thing that I just cannot wrap my head around is, when you say acute pain r/t tissue trauma aeb 7 out of 10 pain.... is that you write these up before you go into the room right? well how do you know if their pain is a 7? do you see it when you get the kardex and the other information from report and you can change it during the eval phase if it is now a 2? Ive been doing the ones in the study guide and one is like the above nsg dx and i just didnt know how they got that number... and I guess thats what actually got me all confused about this in the first place.... :chuckle.... oh my my my. I think Ill get it eventually. :-)

[SuesquatchRN, BSN, RN]

"Acute pain related to tissue trauma as evidenced by "

Aw, heck, now I'm confussled!

[shawnnarae]

Oh No!

:)

[SuesquatchRN, BSN, RN]

I'll look up my notes and post about it tomorrow pm. I'm whipped - I was up at 0300 hours thinking about that stinking syringe and my watch.

[BBFRN, BSN, PhD]

Hey guys- you could make your AEB portion for the scenario, "AEB c/p pain >3 on a 0-10 scale." Your goal should be to have them rate their pain at

Shawnnarae, Daytonite (a long time member here) is also great at teaching care planning. You can do a search for threads that she has posted in, or PM her, if you need help. She is very supportive of the nursing students here.

Good luck to both of you! :)

[shawnnarae]

Thanks! Ill try to look some stuff up. :)

[Daytonite, BSN, RN]

i know that this distance learning forum is out of my territory, but i do know about care planning and nursing diagnosing. it might help if you look at some of my posts and links that are listed at the beginning of this sticky on the general nursing student discussion forum

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

acute pain r/t tissue trauma aeb 7 out of 10 pain

nursing diagnosis: acute pain

related factor (etiology): tissue trauma

defining characteristic(s) [symptoms/supporting evidence]: 7 out of 10 pain

nursing diagnoses are always, always, always based upon the abnormal data that you have collected on your patient. any diagnosis, be it a nursing diagnosis, a medical diagnosis or a plumber diagnosing why your toilet won't flush, is based upon an assessment (or examination) that was done and what was found to be abnormal about the assessment (or examination). that abnormal data is called symptoms by doctors and nanda decided we nurses would call them defining characteristics. so, your patient with acute pain has a defining characteristic for that particular nursing diagnosis of 7 on a scale of 10. that is your evidence that this patient has acute pain, the nursing diagnosis. the tissue trauma part of your diagnostic statement is the reason (cause, etiology) that the pain exists. if the trauma hadn't occurred, then there wouldn't be any pain, period, end of story.

are you asking what the 0 to 10 scale of pain assessment is? i wasn't quite sure if that is what you were getting at after reading your third post several times.

one thing that i just cannot wrap my head around is, when you say acute pain r/t tissue trauma aeb 7 out of 10 pain.... is that you write these up before you go into the room right? well how do you know if their pain is a 7? you determine this by doing an assessment of the patient; an assessment can include looking up what their pain level was documented as being by the last nurse who cared for the patient. it does not necessarily mean data that you yourself have collected. do you see it when you get the kardex and the other information from report and you can change it during the eval phase if it is now a 2?

i tell students all that time that assessment data comes from a lot of different resources and you literally have to play detective:

• your own physical assessment of the patient
  
• 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 other nurses, physical therapists and dietitians
  
• subjective information provided by family and significant others
  

[shawnnarae]

Thanks! I know what the 0-10 pain scale is, it's just that when I am going over all the answers in the study guide it always said acute pain r/t tissue trauma aeb and then it states some number out of 10, and I just had no idea where they got those numbers from and how I am supposed to make a nursing diagnosis when i have no idea what her pain scale is (i guess we make a ncp then go see our pt. i think...) so that was all my confusion.

But thank you again for thta post and I will browse through it. Any help is very much appreciated! :-)