Nursing Diagnosis

[val1232]

COULD ANYONE HELP ME COME UP WITH NURSING DIAGNOSIS FOR THIS CASE STUDY. Greatly appreciate it!

Mark is a 37 year old male who appears unconscious and in cardiac arrest. He is a full code status.

Mark has a family history of cardiac conditions. He was last seen well at 15:30 and was complaining of chest tightness and his heart racing. His wife reported that he said was having trouble breathing and felt lightheaded and dizzy prior to syncope. His wife witnessed his collapse, called EMS and started CPR. Upon arrival, the patient was unconscious with a pulse. EMS intubated him at the scene.

His vital signs are as follows: 98.7, 170, 20, 100/70, and 92% while being bagged with 100% FiO2. The patient has fast, shallow respirations with clear lung sounds. Heart sounds are regular. The ECG shows the patient to be in sinus tach

[k1p1ssk, BSN, RN]

I think you meant to post this in the Nursing School sub? This sub is for school nurses. We can probably come up with a good nursing diagnosis, but 37 year olds in cardiac arrest are not really our wheelhouse... I mean, it could be, but....

a quick Google search (I haven't cracked open my nursing care planning books in 10 years....) gives me: 

Acute Pain. Activity Intolerance. Fear/Anxiety. Risk for Decreased Cardiac Output. Risk for Ineffective Tissue Perfusion. Risk for Excess Fluid Volume. Deficient Knowledge.

good luck!

[Rose_Queen, BSN, MSN, RN]

Moved to Nursing Student Assistance forum for best responses. 

[KrCmommy522, BSN, RN]

What have you come up with? I’ll gladly help you, but gotta know what your thoughts are. 
 

What abnormalities are you seeing in the assessment and vitals? What diagnoses would result from those?

[Hannahbanana, BSN, MSN]

Where is your nursing assessment of his condition? This is all medical diagnoses.
Don’t fall into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to plan nursing care. This is complementary but not dependent on the medical diagnosis or plan of care. If all they give you is a medical diagnosis, you will have to imagine what symptoms he and his family have that would lead you to nursing dx.

I am starting to learn that somehow the idea in nursing school these days is to "pick" a nursing diagnosis. No, it's not. You are in nursing school to begin to learn how to OWN your nursing practice-- you MAKE a nursing diagnosis based on the evidence you see before you, exactly like physicians make medical diagnoses based on evidence. In all fairness, we see ample evidence every day that nursing faculty sometimes have a hard time communicating this concept to new nursing students.

Sure, you have to know about the medical diagnosis and its implications for nursing, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis comes in when you’re planning the nursing care your patient needs and deserves.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts should come first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."  "Surgery" counts for a physical injury-- after all, it's only expensive trauma. ?

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, but they have approved risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2018-2020 (current edition, new one’s due out soon). Around $45 paperback, $29 for your Kindle or iPad at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised! Wonder where you learned that??? ?

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2018, it may be using outdated diagnoses.
We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for: to learn how to plan nursing care.

If you do not have the most current NANDA-I, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now.  When you get it out of the box, first put little sticky tabs on the sections:
1, health promotion (teaching, immunization....)
2, nutrition (ingestion, metabolism, hydration....)
3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
5, perception and cognition (attention, orientation, cognition, communication...)
6, self-perception (hopelessness, loneliness, self-esteem, body image...)
7, role (family relationships, parenting, social interaction...)
8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
10, life principles (hope, spiritual, decisional conflict, nonadherence...)
11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilation...)
12, comfort (physical, environmental, social...)
13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings and at least one of the related / causative factors are present. If so... there's a match. Congratulations! You have made a nursing diagnosis! If not... keep looking. Eventually you will find it easier to do it the other way 'round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.