Data Organization

Directions:

 Using the Domains of NANDA Nursing Diagnosis organize your data from the Nursing Health History

 Choose ONE domain to focus on based from your initial analysis of the data from the health history

 Organize assessment data (both objective and subjective) clustering those that may be related to a singular health problem.

 An example will be given below for your guidance:

Patient A:

 Patient A has the following v/s: HR-98bpm, RR-28cpm, Temp-38.5C, BP-150/95mmHg

 He is restless and disoriented, verbalizing chest pain. He cannot sit still, he is diaphoretic and slightly agitated.

Domain Class Assessment Data Relevant Nursing Potential Diagnosis Definition of Nursing
Knowledge Diagnosis

Activity/ Rest Subjective data: - Chest pain can be a Ineffective cardiac Decrease in oxygen
sign of cardiac tissue tissue perfusion resulting in the failure to
 (+) complaint of ischemia (interruption of nourish the tissues at
chest pain blood supply to tissue) the capillary level
Objective data: - Elevated HR and RR
 HR: 98bpm may be due to the heart
Cardiovascular/ compensating for the
 BP: 150/95mmHg poor oxygenation of
 Responses  RR: 28cpm tissue r/t poor perfusion
or blood flow to the
heart

Subjective data: Chest pain can be a Acute Pain Unpleasant sensory

sign of cardiac tissue and emotional
 (+) complaint of ischemia (interruption of experience arising from
chest pain blood supply to tissue) actual or potential
Objective data: tissue damage or
- Tissue ischemia described in terms of
Physical Comfort
 HR: 98bpm activates anaerobic such damage
respiration in cardiac
Comfort  BP: 150/95mmHg cells leading to release
of lactic acid which
 RR: 28cpm
irritates nerve endings
 Restlessness causing pain

 Diaphoresis - Elevated HR and RR

may be due to the
 Agitation stimulation of SNS as a
result of pain felt
Ineffective Tissue Perfusion That is why you NURSING KNOWLEDGE is important to know the underlying
cause of the patient’s health problem.

Related factors as per NANDA:

Based on data on patient A, Ineffective cardiac tissue perfusion may be a
 Interruption of flow result of ischemia to the heart tissue i.e. interruption of blood flow.
 Exchange problems

 Hypervolemia/ hypovolemia Therefore, the Nursing Diagnosis should be:

 Mechanical reduction of arterial and/or venous blood flow

 Decreased Hb concentration in blood INEFFFECTIVE CARDIAC TISSUE PERFUSION RELATED TO

 Altered affinity of Hb for O2; enzyme poisoning INTERRUPTION OF FLOW AS MANIFESTED BY CHEST PAIN AND
INCREASE IN RESPIRATORY AND PULSE RATE.

Or a four-part statement:

Ineffective cardiac tissue perfusion r/t interruption of flow AMB chest pain and
increased RR and HR secondary to Myocardial Infarction

Acute Pain Based on data on patient A, acutte pain is due to the release of lactic acid
(chemical) as cardiac cells resort to anaerobic respiration due to poor
perfusion.
Related factors as per NANDA:

 Injuring agents (biological, chemical, physical, psychological) Therefore, the Nursing Diagnosis should be:

Acute Pain r/y chemical injuring agents AMB complaint of pain and elevated
 v/s.

Note: the NANDA guide will provide you the definition of the potential diagnosis that you will identify. There are also indicated related factors, defining
characteristics, desired outcome and interventions. You just have to select which is most appropriate for your case based on the assessment findings.
SAMPLEEEEE 😊

Domain Class Assessment Data Relevant Nursing Potential Diagnosis Definition of Nursing
Knowledge Diagnosis

Subjective data: - Chest pain can be a Ineffective Breathing Inspiration and/or

sign of an increased Pattern expiration that does not
 (+) complaint of rate and depth of provide adequate
chest pain breathing. ventilation.
Objective data: - Elevated RR may be
 RR: 28cpm due to tachypnea,
Cardiovascular/ which is a rapid,
Responses  Restlessness shallow breathing, with
Activity/ Rest
more than 24 breaths
 Disoriented
per minute.
 Diaphoresis
-Restlessness,
 Agitation disoriented, and/or
irritability can also be
 Can’t be still early indicators of
insufficient oxygen to
the brain.

Based on data on patient A, Ineffective Breathing Pattern is considered as

Ineffective Breathing Pattern the state in which the rate, depth, timing, and rhythm, or the pattern of
breathing is altered.

Related factors as per NANDA:

Therefore, the Nursing Diagnosis should be:
 Hyperventilation
 Anxiety Ineffective Breathing Pattern r/t hyperventilation as manifested by increased
respiratory rate and complaint of chest pain.