Nursing care plan - nursing diagnosis help

Esme12, ASN, BSN, RN · Jul 15, 2012

1. activity intolerance r/t decreased tissue perfusion and decreased oxygen delivery to cells aeb patient’s subjective complaints of dyspnea with exertion, dizziness, and fatigue.
2. risk for ineffective tissue perfusion r/t surgery: stent placement in the right coronary artery.
3. knowledge deficit related to diagnosis and treatment aeb patient being unable to verbalize his medical diagnosis, the importance of treatment, and medication therapy.
here's my patient's med history: stable angina and coronary heart disease, hypertension, hepatitis c, wilson's disease..
he just had a stent placed 36 hours ago and my instructor said the most important thing to look for after a stent is placed is ineffective tissue perfusion.... she said that would be the #1 nursing diagnosis but i don't know if what i have is correct. he was having chest pain when i assessed him 7/10, but he's been having worsening chest pain for the last 6 months, i think that's part of the reason the stent was put in.
also, wouldn't a "risk for" diagnosis be below activity intolerance because it's still a risk and hasn't necessarily happened?
thanks for the help!
- gemini

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

the third is a good care plan book. i use ackley: nursing diagnosis handbook, 9th edition and gulanick: nursing care plans, 7th edition

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
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)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

just like you need a recipe care to make a cake from scratch. a care plan is your recipe card to caring for your patient and what to look for while you are caring for them.

so your patient has a med history: stable angina and coronary heart disease, hypertension, hepatitis c, wilson's disease..

first of all what is wilson's disease? is his angina now stable since he had to have a stent placed? what is coronary disease? what is htn and hepatitis c? is his hepatitis disease due to the wilson's disease? what does that leave him at risk for? is he at risk for bleeding?

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during your assessment of the patient. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals. from our beloveddaytonite: nursing community | nurses | nursing students

in determining a problem you should always use the nursing process. first, look at the assessment data you have. . .
severe post-op chest painin determining a problem you should always use the nursing process.

so...... he just had a stent placed 36 hours ago and my instructor said the most important thing to look for after a stent is placed is ineffective tissue perfusion.... she said that would be the #1 nursing diagnosis but i don't know if what i have is correct. he was having chest pain when i assessed him 7/10, but he's been having worsening chest pain for the last 6 months, i think that's part of the reason the stent was put in.

what are the implications of having a stent place in the past 36 hours? what is a stent? what risks are associated with this procedure? would the patient have acute pain for this procedure? what else could cause alteration is tissue perfusion due to this procecure....a clot in the leg? bleeding?

first, look at the assessment data you have. . .

severe post-op chest pain
has a history of cad : what is cad? this is important to know because it will have an impact on the pathophysiology of the pain. most chest pain is first ruled out to be of cardiac origin (tissue perfusion problem). once that is ruled out then musculoskeletal or gi sources of the chest pain are considered. is there a reason he was not given nitroglycerin for his chest pain, or a ekg done since he jsut had a stent palced. it could be a lung problem. it could be due to the way he was placed on the surgical table and this is merely a musculoskeletal pain. i can't help you on this, but you need to figure out a cause of why his chest would be hurting for the "related to" part of your nursing diagnostic statement
he described that it was a feeling of dyspnea with exertion, dizziness, and fatigue
when you assessed his pain it was decreased to a 7/10 (this was after receiving pain medication?)

secondly, determine your nursing problem from the abnormal data. . .

acute pain r/t ??? aeb a feeling of patient’s subjective complaints of dyspnea with exertion, dizziness, and fatigue.[this is based on your assessment at the time you took care of the patient]

this is probably musculoskeletal pain. if it were cardiac in origin he would be getting nitroglycerin for the pain and your nursing diagnosis would be decreased cardiac output r/t ischemia.

1) activity intolerance r/t decreased tissue perfusion and decreased oxygen delivery to cells aeb patient’s subjective complaints of .

how do you know the fatigue is due to decreased oxygen delivery to the cells? which cells? could this also be due to the wilson's disease and or hepatitis c?

why would there be an alteration in tissue due to stent placement?

could the patient re-develop a cardiac issue with sudden blockage? could the patient develop alteration in perfusion to the extremity that the procedure was preformed on from sudden arterial occlusion?

could there be a potential alteration in tissue perfusion related to impaired circulation from the arterial stick and procedure? or potential hemmorhage from puncture site or damage to artery from procedure?

could there be an alteration in tissue perfusion due to sudden re-occlusion of coronary artery from fresh stent placement?

it is apparent the patient has an alteration in comfort aeb his complaints of dyspnea with exertion, dizziness, and fatigue....and severe complaints of chest pain aeb 7/10 complaint. what did you do to assess what type of chest pain the patient was having?

the activity intolerance is related to.....what? hep c? wilsons? or is it cardiac in nature?aeb complaints of dyspnea, dizziness and fatigue.

does this make sense?

Gemini25 · Jul 15, 2012

He refused nitro when he was having the chest pain. He refused pain medication. He only had 1 dose of morphine since his surgery....

you are helpful. thank you :)

nurseprnRN, BSN, RN · Jul 16, 2012

if he had a stent for coronary artery disease and he is still having the same kind of chest pain now, the differential would be to give him the ntg and see if it helps. if he refuses, there's a problem. of course a patient can refuse anything; perhaps, though, there's some reason he's refusing that needs to be understood. did you ask why he refuses it? does he think it's addictive or habit-forming? does he understand the mechanism of action has nothing to do c opioids? this may be a nonadherence diagnosis based on a knowledge deficit/fear/whatever, and it behooves nursing to find out why.

of course a 7/10 pain is significant, and it's actual, not a risk. furthermore, i'm not pleased with this rote "actual is more important than risk-for" thing students keep hearing. an actual area of dry skin that's itchy (for example) is not more important and more worthy of your vigilance than angina post stent. someone with very brittle dm has a risk-for diagnosis, right? this is less important than the actual necrotic toe he's got? not really.

Gemini25 · Jul 27, 2012

He said he's taken a lot of nitro in the past and it used to help, but not as much anymore.... that's what he told me. he said it seems like the morephine helps more now, but he didn't end up get either... and he didn't want the morphine by the time I get back.

I agree with your "at risk" stuff being put last just because it's not an actual problem as of yet... but that's what our professors want us to do.