care plan dx chest pain

  1. HELP PLZ.
    This my first year of Nursing School and I still cant seem to get my care plan how my professor wants it.
    My pt is admitted Dx chest pain,cocaine abuse, alcohol abuse.
    Symptoms:Left side with tightness, sharp pain, and numb on left side.Pain was so bad he fell to the ground to his knees
    VS:BP 127/82 Pulse96min Respirations 18min pain 7/10.
    I need help coming up with a full Dx that includes r/t and a.e.b
    I came up with a couple of Dx do these sound ok?
    1.Acute Pain
    2.Risk injury(falling)
    3.Ineffective health maintenance r/t use of drugs a.e.b cocaine and alcohol abuse
  2. Visit L.A.W profile page

    About L.A.W

    Joined: Jan '10; Posts: 20; Likes: 2


  3. by   Rednights

    Acute Confusion
    Chronic Confusion
    Defensive Coping
    Ineffective Denial
    Imbalanced Nutrition
    Impaired Memory
    Risk for Violence (self/others)

    I suggest you buy a NANDA book

    BTW: Make sure you, your prof, or the nurse asks when his last drink was before he goes into withdrawal and you brand new student nurse steps into the room =)
  4. by   L.A.W
    Thanks, and his last drink was the night before he came in the E.R.
  5. by   Daytonite
    the construction of the 3-part diagnostic statement follows this format: [font=arial unicode ms]

    p (problem) - e (etiology) - s (symptoms)
    • problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
    • etiology- also called the related factor by nanda. this is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
    • symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
    you didn't complete all of your diagnoses with the r/t and aeb's as required. diagnosing is based on your assessment of the patient. assessment includes:
    • a health history (review of systems) [font=arial unicode ms]
    • 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
    and then examining the abnormal data. it is the abnormal data that forms the basis for any nursing problems which you then attach names (nursing diagnoses) to. it is important when you are just learning nursing diagnosis that you have and use a nursing diagnosis reference (like the one i reference below). every nursing diagnosis has a definition. the definition is much more broad than the actual label (nursing diagnosis) and you really need to read them so you know exactly what the diagnosis is all about. it also is helpful to read the related factors and defining characteristics (signs and symptoms) that go along with each diagnosis. it will give you a better understanding of the diagnosis before you randomly choose it. if you have a current copy of taber's cyclopedic medical dictionary you will find all this information in the appendix.

    your diagnoses are also sequenced in the incorrect priority of need. they should be:
    1. acute pain
      • to get to the related factor (cause) of the pain you have to know the pathophysiology of what is causing the pain. was it related to the heart? when chest pain is related to the heart it is because the vessels supplying the heart have been deprived of oxygen. this is called ischemia. cocaine tends to do that. you need to read about what the effects of cocaine are on the body.
      • acute pain - definition: unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (international association for the study of pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. (page 354, nanda international nursing diagnoses: definitions and classifications 2009-2011)
      • acute pain r/t ischemia aeb chest pain of 7/10.
    2. ineffective health maintenance r/t use of drugs a.e.b cocaine and alcohol abuse
      • this has an incorrect related factor, or cause, of the nursing problem. the definition of ineffective health maintenance is inability to identify, manage, and/or seek out help to maintain health (page 57, nanda international nursing diagnoses: definitions and classifications 2009-2011). the cause of not managing one's health is not the use of drugs. it has to do with their thinking, judgment, coping skills or inability to be able to perform the tasks the health providers have directed them to. this diagnosis is often used when noncompliance becomes an issue. what you have to do is determine from assessing the patient why they use the drugs. is it a coping mechanism for problems in their life? (ineffective health maintenance r/t ineffective coping aeb cocaine and alcohol abuse) or are they just making inappropriate judgments and using drugs knowing they are bad for them? (ineffective health maintenance r/b inability to make appropriate judgments aeb cocaine and alcohol abuse)
      • or, you could just use ineffective coping r/t to inadequate ability to cope with stress in life.
    3. risk injury(falling)
      • you have 2 diagnoses here: risk for injury and risk for falls. pick one. drug abusers are at risk for injury r/t drug effects.
  6. by   L.A.W
    Thanks so much that really helped me out. Bad news my pt got discharged so my professor doesnt even want me to do that one any more I have a new one and its way more compicated.