Nursing Diagnosis help

[allenichick]

I have been trying to get a correct nursing dx for the patient that I had....

I am totally lost in what to do so here is about my patient

Okay the chief diagnosisis chest pain and sOB with chest tightess.

He had just come back from another hospital the day before and was treated with acute diverticulitis.

It said he had COPD and pneumonia but she said not to do it over that because she thinks they just put that there so he would get admitted.

Here is his history:

Acute Diverticulitis

CAD with cardiac catherization showing patent left internal mammary artery to left anterior descending

Ischemix cardiomyopathy-Ejection Fraction 45-50%

Moderately severe mitral regurgitation

Moderately severe tripsud regurgitation

Chronic kidney disease

Right upper lobe mass, status post brochoscopy and biopsy that was apparently negatice for malignancy

Hypertension

Hypercholesterolmia

other d/x: MI/A fib, PTCA with stents, and CABG

MY NURSING DIAGNOSIS THAT I HAVE SO FAR IS

decreased cardiac output r/t altered heart rate AEB tightness in chest?

maybe another AEB

he has a history of heart problems

and the other one I was going to do Fear r/t past medical procedured AEB bleeding during stent removal

[TheSquire, DNP, APRN, NP]

I'm a big fan of not doing the homework of people who post on message boards, here or elsewhere. However, I do have this piece of advice: get yourself a copy of the Nursing Diagnosis Handbook by Ackley and Ladwig. It's great for students starting out in nursing school and doing the med-surg thing because the front section lists possible Nursing Diagnoses by Medical Diagnosis. Look up some of those issues there and you'll have your careplan filled out in no time. If your school doesn't make you buy it, get a copy for yourself of look it up in your school's library. It should have a copy.

[RNShenanigator]

I am not sure where you are going with the fear thing. "AEB bleeding during stent removal," is not a sign or symptom of fear. Did he express fear? What did he say to express his fear.

The other thing is you said he was admitted for chest pain and SOB. Start with the SOB and Pain.

[RNShenanigator]

Also, you might want to look at the sticky threads about care plans. Daytonite has put some really useful information on care plans and on forming a priority nursing diagnosis. I think she also suggests getting Nursing Care Plans Made Incredibly easy. I have ordered mine from Amazon this week, since care plans always seem to give me trouble also.

Most of the people here are willing to help or at least put in their 2 cents as to whether or not we think you are on the right track. Just remember most of us are students, and may not always be right.

Good luck.

[morningland]

Your diagnosis needs at least 1-2 more AEB. No nursing diagnosis can be based on one. Your fear diagnosis may been the patients expression of fear in the AEB to make it more concrete

[allenichick]

Okay I just wanted to make sure that I am on the right track

We did not get a chance to get his pain level so I did not want to do pain

Fear i chose because he stated that he had past medical procedures that did not go well. which is better fear or anxiety?

So am I on the right track for decreased cardiac output?

Thank you guys for you input

[Daytonite, BSN, RN]

a care plan is about a patient's nursing problems. what you have provided is all kinds of information about the patient's medical problems. nursing problems are the patient's response to their medical and other problems in their life, particularly how they are able to perform their adls. the only nursing related information you have provided is that the patient bled during a previous stent removal which is the basis for their fear. it is not clear to me that this person even had any chest pain or sob which you say was the chief diagnosis. if there is pneumonia, none of your nursing diagnoses reflect any nursing care for someone with pneumonia. what medications was the patient receiving? that will tell you a lot about the medical plan of care for the current admission. when diagnosing, it is extremely important that an assessment of the patient be done to find all abnormal data about them. the abnormal data are the signs and symptoms (clues) of the nursing problems that you will diagnosis and put a label to (nursing diagnoses). these are the things you need to assess to find this data:

• a health history (review of systems)
  
• performing a physical exam
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking