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Nursing diagnoses

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hema2crit hema2crit (New) New

Hi guys! I'm working on an essay right now and the topic is Percutaneous coronary intervention. Do anyone of you can help me what nursing diagnoses I should prioritize with regard to this topic? Any help would be very much appreciated. Thanks in advance. :)

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Hi!

We are happy to help however we need to know what you think first. Are you still in the Philippines? Is the procedure that same as here in the US? What has your research on invasive procedures revealed to you? What do YOU think would be a priority? Is this just for an angio or for an angioplasty/stent placement?

Hi Esme! Thanks for the response. The patient is post balloon angioplasty and insertion of stent. The problems I have identified are fluid volume deficit due to bleeding, acute pain, and risk for infection. Are there any nursing diagnoses that I should include? Thanks.:)

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Are you in the US? We might do our care plans differently here.

The problems I have identified are fluid volume deficit due to bleeding, acute pain, and risk for infection.

Here in the US...you could NOT use fluid volume deficit without a fluid volume deficit. What symptoms is your patient showing that proves they have a fluid deficit. I n the US it would state deficient fluid volume: NANDA defines this as...Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level. The patient must exhibit signs that they have a deficit....Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level.

If your patient hasn't had a blood loss then this cannot be used.

Do you use NANDA?

Hi Esme! According to the case there's a large pool of blood all over the patient's sheet and a leakage on the catheter site as well as his BP has dropped from 120/80 to 100/70 and his hear rate is increased, from 80 beats/min to 120 beats/min. He has pain in the groin area and his hands feel clammy, pale, and cool. Yeah, we use NANDA.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Hi Esme! According to the case there's alarge pool of blood all over the patient's sheet and a leakage on the catheter site as well as his BP has dropped from 120/80 to 100/70 and his heart rate is increased, from 80 beats/min to 120 beats/min. He has pain in the groin area and his hands feel clammy, pale, and cool. Yeah, we use NANDA.
Care plans are all about the patient assessment...what the patients needs. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

Ok now that you have provided some assessment...looking at this...what concerns you about this patient? Ignore NANDA for a moment you patient looks like this with a big pool of blood a low B/P and is cold and clammy what is your first response? What do you think of first?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Hi Esme! According to the case there's a large pool of blood all over the patient's sheet and a leakage on the catheter site as well as his BP has dropped from 120/80 to 100/70 and his hear rate is increased, from 80 beats/min to 120 beats/min. He has pain in the groin area and his hands feel clammy, pale, and cool. Yeah, we use NANDA.

What other NANDA diagnosis may apply to this patient?