robinhood76

Hello Daytonite, Thanks for replying to my query, I get your point, but since Iam asked to make only 4 Nursing problems .My main concern is not whether pain should be considered as a Nrsg problem but whether the 4 diagnosis that I have already made is correct or not. If my findings is incorrect ,could you please tell me where I went wrong. I thank you for all the assistance in this regard.

Hi im first year Nursing student having difficulty with the concept map. My case study is like this: Mr. P, 66 years old, calls to complain about shortness of breath and pain that started suddenly and feels like a knife. He states the pain gets worse with breathing. He is diaphoretic, and states he is having difficulty getting a full breath. On inspection, his left chest wall is not moving. His trachea is deviated to the right. On auscultation, he has no air entry. Vital signs T-36.6 P-100 RR-32 BP 100/70. Although I figured out that the patient is suffering from Pneumothorax which is the chief medical Dx, I'm expected to come up with 4 Nursing Dx and also the Dx need to be " Actual problems" and not " Potential problems". After researching from books, i found out that Impaired gas exchange as the 1st Nrsg problem, Ineffective airway clearance as 2nd Nsrg Problem, Activity intolerance as 3rd Nrsg problem, Ineffective breathing pattern as the 4 th problem. Iam very much worried that I might be not in the right tract as the 1st problem and 4th problem is very much similar .My concerns are am I ignoring that pain as one of the problem? but since pneumothorax is essentially a result of injury/trauma in pleural space . How can pain be Nursing problem? Im very confused and frustrated with this concept map. I would appreciate if anyone would help me to figure out the actual problems and Interventions.

Hi,i understand that you are unable to make concept map,. I know that my cheif medical diagnosis is Pneumonia, but i dont know the 4 nursing diagnosis categories which i can segregate the data into. I tried to rationalise and came up with Cheif Medical Diagnosis: Pneumonia Patient has a history of PVD related to 60 years of smoking She has decreased air entry to upper left lobe She is coughing up greenish thick sputum __________________________________________________________________________________ Nursing Dx #1: Impaired skin integrity r/t to immobility she has a stage X ulcer covered with dry intact eschar. ulcer is on the coccyx and is 10 multiply by10 cm. Her left heel is intact but has a blue tinge. Patient has a history of PVD related to 60 years of smoking ___________________________________________________________________________________ Nursing Dx#2: Altered tissue perfusion :peripheral related to inadequate venous return and immobility. She has no pedal pulses on her left foot.The foot is cool to touch. she is complaining of being cold and asking for another blanket.

Hi, i need help with my concept map for the pt,Age 80 years old, weights 90 lbs, she is 5'9'. She was admitted with pnuemonia. She is living in a nursing home. she has a stage X ulcer covered with dry intact eschar. the ulcer is on the coccyx and is 10 multiply by 10 cm. Her left heel is intact but has a blue tinge. Patient has a history of PVD related to 60 years of smoking.. She quit 2 years ago when she entered the nursing home. She has no pedal pulses on her left foot. The foot is cool to touch. She is coughing up greenish thick sputum. She has decreased air entry to upper left lobe. she is complaining of being cold and asking for another blanket.IV 2/3 & 1/3 with 20 KCL at 100ml/hr in left hand. VS T 37 - HR 80- RR 24 Bp 130/90.