nursing diagnoses help please!

Published

I had a pt. who was admitted over two weeks ago for the following: chest pain, abdominal pain, and an extremely high BP. After he was admitted, it was found he had suffered an M.I. Pt. also has diabetes, which had been previously untreated. While in the hospital, pt. developed pneumonia, a UTI, was found to have gallstones, and got C. Diff. Pt. also had restraints due to falling 2X during stay.

While I was caring for him, his BP was 120/80 in the morning, but fell to 93/45 in the afternoon w/out any BP meds. His pulse was consistently around 50 bpm, but in the weeks prior it had ranged from 60-80 bpm. And most importantly, his respirations were at 26/minute in the morning, and by the afternoon had risen to 38/minute. I don't know why he was having a drop in vital signs- I reported each reading to the nurse on duty and to my clinical instructor, and right as we were leaving, the physician came to do an evaluation on him. I never found out the reason for the abnormalities. He complained of no pain, and from what I read in his charts, his pneumonia was resolving.

I am trying to think of a good nursing diagnoses to write my care plan on, and with all that was going on with him (and me being a first semester nursing student), I'm drawing a blank. I already have risk for impaired skin integrity and risk for falls (those are a given in his situation), but I'm not sure if I should attempt Ineffective Breathing Pattern because of his respiration rates or Decreased Cardiac Output because of his respiration rate/heart rate/and BP and recent MI. Any help would be appreciated, and if I'm heading in the wrong direction, please let me know! Also, there's not a nursing diagnoses that could be used related to C. Diff., is there? Thanks so much!

Up Vote Up Vote ×

sounds like he may have had a P.E start from head to toe and do a "systems check" pull from each of his systems the problems he has and prioritize what is going on w/him u should be able to pull a diagnosis from ur problems list. ie: neuro: confusion, resp: PN, cough, dyspnea, cardio/vasc: MI etc, u see where i am going? i think it is called concepting I just learned it this yr and wished i learned it yrs ago takes time to train ur thinking but it helps I am still learning too...but now that i have posted maybe some of the others will jump in and assit u too. good luck

Up Vote Up Vote ×

Hi, this is my first post I am a nursing student that will be graduating in May. I have a few ideas about your problem. First, risk for falls and risk for impaired skin integrity are good but they are only risk. Your main nursing diagnosis should be an actual problem like decreased perfusion for decrease cardiac output.. I would almost think that your patient is going into heart failure. One of the main causes of heart failure is a MI it causes right and left heart failure. I would read up on heart failure and see if your patient has any symptoms.. Inceased resp. dereased b/p heart rate would initially go up but then drop b/c no longer able to compensate. Swelling??? Look up Heart failure and then look up decreased cardiac output and see if that fits.. You want to go with the most critical diagnosis. If your not pumping blood effectively its never a good thing.. This may not help just thought I should tell you what I would do. Good Luck.

Up Vote Up Vote ×

ohh and C. Diff.. I don't think their is a direct diagnosis for it but you could always do with hypovolemia r/t chronic Diarreah or something of the sort you probably have enough data to support that.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

follow the steps of the nursing process to help you. . .

step 1 assessment - assessment consists of:

  • a health history (review of systems) - patient was admitted with chest pain, abdominal pain, extremely high bp, and m.i. and has a history of diabetes that was previously untreated. while an inpatient he has developed pneumonia, a uti, found to have gallstones, and gotten c. diff. - this is a sick guy
  • performing a physical exam - the only physical data you presented was his vital signs. i would have expected to see an assessment of the lungs sounds and sputum (because of the pneumonia) as well as heart sounds or pulses (because of having an mi). since he was admitted with chest pain and did have an mi it is likely that he has cad going on although it was never mentioned. the hypertension fits in with that picture as well as the diabetes. do you have labs showing blood glucoses? how about fingersticks? is he still having diarrhea or other symptoms associated with the c. diff? there is a lot of assessment information missing because from the historical information listed this should be a care plan with a long list of nursing problems. the hypotension might indicate that he has had serious heart damage.
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) -this patient has been in the hospital for 2 weeks and what does he need nurses for? did you help him do anything? is he weak? what self-care deficits does he have? what does he need assistance with?
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to be looking up the following conditions and comparing the textbook signs and symptoms with the ones your patient actually had to see if you missed noticing one:

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - is he on any beta blockers that might be contributing to his hypotension and low heart rate? what drugs is the patient getting now and why? restraints are a medical treatment and there are implications to the use of them.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is all you provided that is useful to care planning

  • respirations were at 26/minute in the morning, and by the afternoon had risen to 38/minute
  • bp was 120/80 in the morning, but fell to 93/45 in the afternoon w/out any bp meds
  • pulse was consistently around 50 bpm
  • fell twice during hospital stay

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

  • this is hard to tell, but because of the medical diagnosis this is most likely ineffective airway clearance r/t retained secretions and inflammatory process in lungs aeb elevation in respiratory rate from 26/minute in the morning to 38/minute in the afternoon
  • decreased cardiac output r/t altered stroke volume aeb hypotension of 93/45 and bradycardia of 50 bpm.
  • risk for falls r/t history of 2 previous falls, c-diff diarrhea, and hypotension
  • there is a lot more missing here because of the missing assessment data:
    • activity intolerance
    • impaired gas exchange - this is a given in people with pneumonia
    • fluid volume problems - this is expected in people who have had mis and are losing fluid because of diarrhea. any edema?
    • nutrition and electrolyte problems - this patient is diabetic and has gallstones. were the gallstones removed? if not, then dietary restrictions need to be observed to allay the onset of cholecystitis.
    • any pain now?
    • problems with physical mobility?
    • self-care deficits and assistance with bathing, dressing, eating
    • anxiety - people who have had mi are usually scared of dying
    • skin integrity problems because of the diarrhea
    • risk for injury - this is secondary to being restrained. is there a foley? were any other invasive procedures done that could result in a potential injury?
    • deficient knowledge - of the diabetes and heart disease

step #3 planning (write measurable goals/outcomes and nursing interventions)

-------------------------------------

also, there's not a nursing diagnoses that could be used related to c. diff., is there?

diagnosing is based on the signs and symptoms the patient exhibits.
c. diff
, or
clostridium difficile,
colitis is a medical diagnosis and as such has specific symptoms. diarrhea, abdominal cramping and abdominal pain are the most common symptoms. those are what you use to diagnose this nursing problem. a complication can be skin breakdown because of repeated skin cleaning. fluid imbalances and weight loss can also occur if the condition goes undiagnosed for a long period of time. the associated nursing diagnoses for some of those are
diarrhea
,
acute pain
and
risk for impaired skin integrity
. as i mentioned above, everything depends on the assessment data that is collected. evidence is needed to prove what nursing problems we have. it's like putting together a jigsaw puzzle except you don't always know what the final picture looks like when you start. you take all the data and start putting it together to make some kind of logical picture.

Up Vote Up Vote ×

Thanks guys for the insight.... my instructor liked my care plan, so all is well. :) I ended up going with decreased cardiac output and ineffective breathing pattern. Thanks again.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

Good for you! Good luck with the next care plan! :heartbeat

Up Vote Up Vote ×
+ Join the Discussion