Nursing diagnosis (again!)

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So here is the rundown:

82 y.o. male who came in with c/o chest pain. He was given nitro and fentanyl and given a CXR which revealed cardiomegaly and mediastinal widening with mass like projection. His chest pain is now controlled, and according to the nurse, he would have been sent home if not for the discovery on the CXR. He has + 2 pitting edema both lower extremeties. Hx of CAD, CABG x 3 vessels, a-fib, pacemaker, HTN, PVD, DM2, CKD stage III, anemia. He was given 2 units of PRBS last night as well as 1 unit FFP. INR today 1.45, so he was ok'd for a biopsy (which they let me watch and was way cool). His labs showed anemia. Glucose is uncontrolled, today was 274 in AM, 313 at lunch (this is after being NPO midnight). We held his insulin in AM due to being NPO and he has a rapid response to Novolog with a tendency to drop according to nurse. They suspect lymphoma or lung cancer. When we talked, he went on and on about his family, how he provided well for them, their education, and his excitement of being a great-grandfather in May. He also kept saying, "Just b/c they found something, doesn't mean it is malignant. It may just be nothing at all!" When I did my assessment, I could not find much - he has a band-aid on his toe, he ripped a toenail off the day before, he noted a cough which he noticed today, non productive. He has urgency when he needs to urinate.

So, here are the few dx I thought of...my signature question, am I on the right track?

1. Decreased cardiac output r/t altered preload and afterload AEB edema, fatigue, c/o dyspnea on exertion.

2. Activity intolerance r/t imbalance between oxygen supply/demand, generalized weakness AEB reports of exertional dyspnea and fatigue, anemia.

3. Risk for situational low self esteem r/t functional impairment, physical illness, and social role change.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Quote
1. Decreased cardiac output r/t altered preload and afterload AEB edema, fatigue, c/o dyspnea on exertion.

2. Activity intolerance r/t imbalance between oxygen supply/demand, generalized weakness AEB reports of exertional dyspnea and fatigue, anemia.

3. Risk for situational low self esteem r/t functional impairment, physical illness, and social role change.

I would reword number 2) Activity intolerance r/t imbalance between oxygen supply/demand, anemia AEB reports of generalized weakness, exertional dyspnea and fatigue.

Try to address stress about possible malignant diagnosis.

Good Job!

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I put the stress down in my documentation to support this dx. I am happy to have something right on track! =] =] =]

Your book you recommended is very nice! =]

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I still don't understand why they don't recommend it.

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Who knows. The books that they recommend have a goal/outcomes section and interventions with rationale's in them, so maybe that is why? I don't know! =]

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

At one time this book was a nightmare to understand but that has changed. Now it is the holy grail.

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Specializes in CVICU.
takingcare19 said:
I put the stress down in my documentation to support this dx. I am happy to have something right on track! =] =] =]

Your book you recommended is very nice! =]

What book is this? Will be checking it out when I start nursing school :]

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
righteousjenn said:
What book is this? Will be checking it out when I start nursing school :]

Nursing Diagnoses 2015-17: Definitions and Classification (NANDA Nursing Diagnoses): 9781118914939: Medicine & Health Science Books @ Amazon.com

The new version will be released on Oct 6th

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Specializes in CVICU.
Esme12 said:

Thank you!! I start in January so it's coming out just in time. :]

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

There is an old one now but my advice wait for the new one they change it so the wording is different and have added some new nursing diagnosis statements.

I do not normally recommend that students be untruthful to their instrucotrs however if your program doesn't "allow" this reference I would keep it under your hat as it is the real resource for NANDA and care plans.

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Specializes in CVICU.
Esme12 said:
There is an old one now but my advice wait for the new one they change it so the wording is different and have added some new nursing diagnosis statements.

I do not normally recommend that students be untruthful to their instrucotrs however if your program doesn't "allow" this reference I would keep it under your hat as it is the real resource for NANDA and care plans.

Hmm that's interesting.. I did not know that certain books are "off limits" to students in terms of referencing... How would you go about keeping it low key since don't you have to reference sources on a care plan(since I'm not a nursing student yet I an going by the numerous Youtube videos I have seen about them)??

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
righteousjenn said:
Hmm that's interesting.. I did not know that certain books are "off limits" to students in terms of referencing... How would you go about keeping it low key since don't you have to reference sources on a care plan(since I'm not a nursing student yet I an going by the numerous Youtube videos I have seen about them)??

There are many who don't mention it at all. I have heard rumor of a couple that said it can't be used and mandate another care plan resource. Use both and cite one. However I would never "recommend it" :saint:

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