1st post and 5th week of nursing school. HELP!

[tidwella980]

We are just now being introduced to nursing diagnosis and got our first care plan assignment that's due Monday. When reading the case study, I just see a whole bunch of symptoms and I'm having a very hard time picking out the stuff for the diagnosis. I'm having a hard time picking a MAIN diagnosis for the patient, along with the r/t and aed/amb. I'm not looking for anyone to do this for me...just some pointers in the right direction would be nice. I don't even know where to begin...

Thanks so much!!

Heres the case study!

Your patient is a 70 year old male who presented at the ER with chest pain and shortness of breath. The history shows he has had a swollen leg with pain for 4 days prior to coming to the ER. He is admitted to your unit. He has significant swelling and mottled erythema of his left leg pain 5/10 while his chest pain is 10/10. The electrocardiogram shows he has atrial fibrillation. The diagnostic work shows that he has a large thrombosis in the left popliteal vein and evidence of a pulmonary embolism. The doctor has ordered he be started on IV anticoagulation therapy, best rest and O2 therapy. Physical assessment reveals diminished breath sounds in the bases. BP 130/80, P 106 and irregular, R 22, T 99 F.

[tidwella980]

Okay so I my instructor wants us to come up with three nursing diagnoses and then pick one to create a care plan. Here's what I have so far:

1. Acute pain r/t obstruction of pulmonary arterial blood flow aeb pain 10/10 and evidence of embolus.

2. Impaired gas exchanged r/t altered blood flow to alveoli secondary to lodged embolus aeb shortness of breath.

3. Ineffective peripheral tissue perfusion r/t deep vein thrombus formation aeb swollen left leg, 5/10 pain with mottled erythema.

Are these done accurately? I wasn't too sure about the priority. I know that breathing is the 1st, but with this patient, it says it was upon admission and now Dr. has ordered he be on O2 therapy. The reason I put pain first was because pt. stated pain being 10/10.

This is pertaining to the case study I posted in the original post.

Thanks so much for everyone's input! It really means a lot. I just want to make sure I am doing this accurately. I know that this is a very important skill to master!

[Esme12, ASN, BSN, RN]

Okay so I my instructor wants us to come up with three nursing diagnoses and then pick one to create a care plan. Here's what I have so far:

1. Acute pain r/t obstruction of pulmonary arterial blood flow aeb pain 10/10 and evidence of embolus.

2. Impaired gas exchanged r/t altered blood flow to alveoli secondary to lodged embolus aeb shortness of breath.

3. Ineffective peripheral tissue perfusion r/t deep vein thrombus formation aeb swollen left leg, 5/10 pain with mottled erythema.

Are these done accurately? I wasn't too sure about the priority. I know that breathing is the 1st, but with this patient, it says it was upon admission and now Dr. has ordered he be on O2 therapy. The reason I put pain first was because pt. stated pain being 10/10.

This is pertaining to the case study I posted in the original post.

Thanks so much for everyone's input! It really means a lot. I just want to make sure I am doing this accurately. I know that this is a very important skill to master!

YOU are thinking in the right direction. Your critical thinking is on the right path. Priority has nothing to do with the presentation....if someone came in for a broken arm and proceeded to have a heart attack...the heart attack becomes the priority. Do you have a care plan book? Which one do you have?

Looking at your presenting scenario, your answer is there.......

is a 70 year old male who presented at the ER with chest pain and shortness of breath. The history shows he has had a swollen leg with pain for 4 days prior to coming to the ER. He is admitted to your unit. He has significant swelling and mottled erythema of his left leg pain 5/10 while his chest pain is 10/10. The electrocardiogram shows he has atrial fibrillation. The diagnostic work shows that he has a large thrombosis in the left popliteal vein and evidence of a pulmonary embolism. The doctor has ordered he be started on IV anti-coagulation therapy, best rest and O2 therapy. Physical assessment reveals diminished breath sounds in the bases. BP 130/80, P 106 and irregular, R 22, T 99 F.

so.........your patient has chest pain that is a 10 out of 10. He has evidence of a Pulmonary embolism. From your research you have discovered that Patients with Pulmonary embolism can code and die as well as suffer from severe hypoxia.

Pulmonary embolism is a common and potentially lethal condition. Most patients who succumb to pulmonary embolism do so within the first few hours of the event. Despite diagnostic advances, delays in pulmonary embolism diagnosis are common and represent an important issue.As a cause of sudden death, massive pulmonary embolism is second only to sudden cardiac death

medscape requires registration but it is free. It is full of sources and articles that are EXCELLENT.Medscape: Medscape Access

Therefore.....your patient has

1) Acute pain R/T obstruction of pulmonary arterial blood flow due to pulmonary embolism AEB verbalized chest pain rated 10/10

2) Impaired gas exchanged r/t altered blood flow to alveoli secondary to lodged embolus causing a blockage in the pulmonary artery or one of its branches AEB shortness of breath. (normally there would be an O2 sat documented and/or ABG's: arterial blood gasses to document hypoxia)

3) Ineffective peripheral tissue perfusion R/T deep vein thrombus formation AEB swollen left leg, 5/10 pain with mottled erythema.

See where this goes?

[Summers_Off]

I think you've gotten lots of great responses. I just wanted to second that the Ackley nursing diagnosis handbook is one of the best ones out there. I love it.... well, as much as you can love a care plan book . Good luck in school! It's been an awesome experience for me.... so far at least.

[tidwella980]

Yes thanks so much! Seriously, I'm already understanding this whole thing better. Actually I have been using Ackley's 9th edition. Its great!

[nurseladybug12]

What my school had us do for care plans is make 3 or 4 categories of symptoms: airway, cardiovascular, pain for example and under these, list the symptoms that contribute to these categories which would be used for your aeb. Then, I would go into my NANDA book by Ackley and in the front there is an alphabetized index of common disorders such as pulmonary embolism and all the possible nursing diagnoses that would be relevant to a pulmonary embolism. Now from that list, you go to the pages that describe the paramaters for something like " impaired gas exchange" and the symptoms should fit the diagnosis, if they dont exactly fit then try another diagnosis that is similar. Your aeb has to be very detailed and the careplans should not contain "medical" diagnoses but nursing ones. Anything that is a human response is a nursing diagnosis, for example, pain, diarrhea, ineffective coping, denial, risk for infection are nursing diagnoses. Your teacher is probably going to want you to create different ones every week instead of using the same ones over and over which is a good thing. You should flip through and see what's there. Also, there are interventions in the book tha tyou can put on your care plan to help you create goals. Goodluck, care plans are always challenging but you will learn a lot from them.

[Esme12, ASN, BSN, RN]

Yes thanks so much! Seriously, I'm already understanding this whole thing better. Actually I have been using Ackley's 9th edition. Its great!

I use Ackley's as well!