Question

Harry Tonka entered the emergency department with midsternal chest pain, which started while he was playing basketball at the gym. Harry Tonka is 42 years old and 5’10” tall, and he weighs 205 pounds. He smokes one pack of cigarettes per day and works in an office. On admission, he reports nausea but no vomiting and no diaphoresis. His blood pressure is 175/92 mm Hg; his temperature is 99° F, pulse is 127 beats per minute, and respiration rate is 20 breaths per minute. He has a history of hypertension, which has been controlled with medication. He states that he forgot to take his medicine today.

Nursing Assessment

An electrocardiogram (ECG) has been performed which is normal. A monitor has been attached to the client. Cardiac marker blood work have been drawn (troponin T or I, creatine kinase MB) and are within normal ranges (negative). The labs will be repeated in 4-6 hours. He is anxious and constantly asking if his heart monitor “looks all right.”

1. Select possible nursing diagnoses for this client. Do this by looking at the list of nursing diagnoses in, the book, Ackley/Ladwig Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Possible nursing diagnoses (at least 3): ________________________________________________   

       

2. Validate the possible nursing diagnoses.

Compare the signs and symptoms (defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. Also read the definition and determine if this diagnosis fits this client.

Validated nursing diagnoses include (at least 2): ________________________________________

____

Write/select a 3-part nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the related to (r/t) factors and evidence (AEB). Recall (PES = problem/etiology/symptoms & signs).

1. The label is the title of the nursing diagnosis as defined by NANDA.
2. A related to (r/t) statement describes factors that may be contributing to or causing the problem that resulted in the nursing diagnosis.

NANDA label:

Definition:

Defining Characteristics:

Related Factors (r/t):

The complete nursing diagnostic statement is:

1. PLAN

1. Select appropriate outcome goals from Ackley/Ladwig text. Identify one as a LTG, one a STG.

STG:

LTG:

2. Provide three appropriate interventions. You do NOT need to write out the rationales for these for this assignment (for a care plan, you would).

Interventions for the STG:                                        

   

Interventions for the LTG:

Answer 1

1.Acute pain in the mid sternal region related to high blood pressure as evidenced by pain scale reading

Definition:Pain is whatever the experiencing person says it is, existing whenever the person says it does; an unpleasant sensory or emotional experience arising from actual or potential tissue damage or described in terms of those damage sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of.

Defining Characteristics

• patient reports pain
• changes in appetite
• nausea
• anxious

Related Factors

• High blood pressure

Short term Goal

• Patient states there is no longer suffering from midsternal pain

Interventions

• Assess the characteristics such as location and intensity of the pain
• Ask the patient to take rest during severe pain episodes.
• Reassure the patient
• Provide a fowlers position to the patient
• provide medications as prescribed by the doctor

Long term Goal

• Patient maintains the blood pressure within normal range by taking medication appropriately

Interventions

• Remind the patient regarding importance of taking anti hypertensive medicines on time.
• Advice the patient to keep a reminder in mobile phone to avoid skipping of medication
• advice the patient regarding activities he must avoid

2.Anxiety related to fear of death as evidenced by frequent questioning

Definition

• Anxiety is a feeling of worry,nervousness,or unease about something with an uncertain outcome

Defining Characteristics

• restlessness
• frequent questioning

Short term Goal

• To keep the patient calm

Interventions

• Talk to the patient
• Explain the treatment methods
• Therapeutic touch
• Reassure the patient

Long term goal

• Patient will be able to understand the condition and have adequate knowledge regarding the occurance of the pain

Intervention

• Explain the reason why it occured.
• Advice the patient how to avoid these episodes again
• Explain the condition to the patient relative

3. Risk for decreased cardiac output related to elevated blood pressure as evidenced

Definition

• inadequate blood pumped by the heart to meet metabolic demand of the body

Defining characteristics

• Abnormal heart rate

Short term goal

• Take measures to reduce blood pressure to normal
• continuous monitoring
• Medications as prescribes

Long term goal

• Patient does not goes to any other complications

Interventions

• Continuous monitoring
• Collect an appropriate health history
• Further investigations such as 2D echo to rule out complications at the earliest
• Angiography can be done

Answer 2

Possible nursing diagnosis: activity intolerance r/t acute pain