Is the patient conscious?
I would start with the obviouse
Alteration in comfort
Knowledge deficit
Fear
impaired ventilation
communication impaired
When you look at your patient -what do you see? Drawyour diagnoses from that and extrapolate by the defining charactaristics.
I would suggest you look into buying the nurses pocket guide to diagnoses,Interventions and Rationals - It's a great little guide that fits in your pocket. I have been using it since school and it's the best book ever.
Hppy