[margaretptz]

I have to do three nursing dx for this fictitous patient. I have just finished fundamentals and am taking a summer skills seminar. The others in the class have completed 3 semesters so I am feeling q bit behind the others. Anyway I would like to choose the top three but I am unsure if ineffective airway clearance is correct or if it is risk for ineffective airway clearance.

The reason I am not sure is that even though she is hypoxic and has a cough, the cough is productive which to me indicates the airway is being cleared when she coughs up the mucous. The doctor has also ordered a cough suppressant which I thought wouldn't have been ordered if she needed to cough to clear the airway. Advice please. If I use the ineffective airway clearance I would r/t it to immobility and cough with thick secretions aeb the mucous and pO2 of 60mm Hg.A.C.

the scenario is a 70 year old female just admitted to your medical unit. Her chief complaint is fever and cough productive of thick, yellow mucous for three weeks. She was admitted due to her overall poor condition and hypoxia with pO2 of 60 mm Hg on room air. Her medical history includes: 20-year history of multiple sclerosis resulting in paraplegia, chronic non-healing sacral pressure ulcer 3 cm x 3 cm x 2 cm; hypertension controlled with diuretic therapy; recent diagnosis of intraabdominal mass.

Current orders include: soft diet; assist to chair tid; O2 by cannula at 2 L/min; daily wet to dry dressing to sacral wound; vs q4h; I & O q12h; EGD to be scheduled. Med orders are: Percocet 1 tab p.o. q6h; Baclofen 20 mg p.o qid; Lovenox 40 mg subcut daily; fluoxetine 30 mg p.o daily; gabapentin 300 mg p.o. tid; hydrochlorthiazide 12.5 mg p.o. daily; lorazepam 2 mg p.o. qid; MVI with minerals 1 tab p.o. daily; codeine/guaifenesin syrup 5 ml p.o. q6h prn cough; Silvadene topical apply to wound with wound care daily; MOM 30 ml p.o. now

Additionally, on admission her Hgb is 7.8 g and Hct 25.1% and she is to receive 2 units of packed red cells over 4 hours.

Admission vital signs are temp 99, pulse 100 regular, RR 18, BP 92/40, O2 sat has improved to 92% on O2 at 2L/min. She is awake and alert, oriented x3, c/o RUQ abd pain 8/10 unrelieved by Percocet given on admission. She has strong & equal grips with both hands; very weak but equal motor ability of lower extremities; 2+ pedal edema noted bilateral. Her abdomen is distended and tender to palpation with active bowel sounds. Her husband is at the bedside discussing his plan for getting her back to Maine for the summer; he also mentions that she hasn't had a bowel movement in several days.



I am also planning on using a NX of impaired skin integrity r/t immobility, mechanical forces and chronic disease process aeb the 3x3x2 wound.

For the third DX I don't know if I should use constipation, percieved constipation, or acute pain. I also realize I need to address the anemia after the airway but I can't find a DX I can use.

I could also use risk for infection,or risk for falls, and I think the husband may be having some denial as he is planning a summer trip for her, but I don't know how to address that. Knowledge deficit r/t diagnosed mass?

Any suggestions would be very kindly welcomed.
Thanx
Margaret

[nsgmjr]

for anemia Impaired gas exchange R/T decreased oxygen carrying capacity aeb hg 7.8

[Daytonite]

OK. You are writing a care plan. You go through the steps of the nursing process. Do this step by step with the information you have been given.

Step #1 - Assessment
Go through the information that you have been given about the patient. Close your eyes and pretend that you are doing the physical assessment, interview and reviewing her medical record. They gave you a lot of information. You listed much of it in your post. Extract it out and put it into a list.


Step #2 - Formulate your Nursing Diagnoses (this is the step you are primarily stuck on)

Substep (A) - Make a list of the abnormal data

Look at all the assessment items and pull out the ones that aren't normal. Here's the list I got:

• fever (Temp 99)

• hypoxia with PO2 of 60mmHg on room air

productive cough of thick, yellow mucous X 3 weeks

Pulse 100 and regular (slightly high)

B/P 92/40 (low)

abdominal pain 8/10 unrelieved by Percocet

abdomen distended

abdomen tender to palpation

no BM for several days

chronic non-healing sacral pressure ulcer 3cm x 3cm

weak motor ability of lower extremities

2+ pedal edema bilaterally

Hbg 7.8 (low)

Hct 25.1% (low)

Substep (B) - List the medical diagnoses and look up their symptoms

• multiple sclerosis
• chronic non-healing sacral pressure ulcer 3cm x 3cm
• hypertension
• intra-abdominal mass

Substep (C) - Check the textbook symptoms in Substep (B) against your assessment data and your doctor's orders

Ask and answer these questions:

Does everything from A match with something from B?

Does each of the different physician's orders match up as a treatment for one of the symptoms from A or B?

Does it seem like there are any symptoms or manifestations of any of the medical diagnoses in Substep B that weren't mentioned in the scenario and got left out? Do I need to assume they exist anyway (since this is a fictitious patient)?

How are you going to address ADLs?

At this point, you may want to go back and re-assess, based on new information you have after looking up the signs and symptoms of the 4 medical conditions. You may want to include more symptoms in the abnormal data in Substep (A). Since we are nurses, assessing ADLs is important. You've already been told this lady is a paraplegic and that already has had and will have a big impact on her care.

Substep (D) - Start looking for Nursing Diagnoses that have Defining Characteristics that match with one or more of things on your list of symptoms in Substep (A)

To do this, you will need a book or a reference with nursing diagnoses in it. Each nursing diagnosis has a definition, a list of defining characteristics (symptoms) and related factors (causes or etiologies) [worry about those later].

I'm going through my copy of NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International and here's what I'm coming up with:

• Impaired Gas Exchange (AEB hypoxia and tachycardia--you'll also add the information about the PO2 of 60mmHg on room air and the pulse rate of 100)
• Ineffective Airway Clearance (AEB excessive sputum--that's referring to all that thick yellow sputum the patient has been coughing up for the last 3 weeks. How much sputum do you cough up every day?)
• Constipation (AEB abdominal pain, abdominal tenderness, distended abdomen, and palpable abdominal mass--that's your patient's abdominal pain 8/10 unrelieved by Percocet, abdomen tender to palpation, distended abdomen, and husband's statement of no BM for several days)
• Impaired Skin Integrity (AEB disruption of skin surface--that's your chronic non-healing sacral pressure ulcer 3cm x 3cm)

I'm stopping here because going any further is getting into pretty complicated pathophysiology and you don't have enough information about the patient to go into cardiac outputs and what might be causing the anemia and hypotension. With her medical diagnosis of multiple sclerosis you can certainly go for any of the Self-care Deficits, but you really weren't given any specific information about them. As I was going through the information you were given and looking at my NANDA reference I was seeing that you were given specific information to get to at least those four nursing diagnoses. And, you only need three, right?

To expand on them and add the related factors you merely look at the circumstances causing the defining characteristics your patient is displaying. Your nursing diagnostic statements follow the order of PES (problem-etiology-symptoms) where the problem is the nursing diagnosis, the etiology is the related factor and the symptoms are the defining characteristics. This is what I come up with, in order of priority:

• Impaired Gas Exchange R/T ventilation perfusion imbalance AEB hypoxia with a PO2 of 60mmHg on room air and tachycardia with a pulse rate of 100.
• Ineffective Airway Clearance R/T excessive mucus production AEB thick yellow sputum the patient has been coughing up for the last 3 weeks.
• Constipation R/T immobility and side effects of antidepressants [you'll need to check the side effects of the drugs she's getting] AEB abdominal pain 8/10 unrelieved by Percocet, abdomen tender to palpation, distended abdomen, and husband's statement of no BM for several days.
• Impaired Skin Integrity R/T disruption of skin surface AEB a chronic non-healing sacral pressure ulcer 3cm x 3cm.

Step #3 - Planning

Now! You get to write the measurable outcomes (goals) and nursing interventions. For each of those problems that got turned into AEB items in the nursing diagnoses, you now start to develop nursing interventions. Your outcomes (or goals) are your predictions and resolutions of the problems. You have so many to choose from!

Step #4 - Implementation
Step #5 - Evaluation

There you go. . .Some after thoughts. . .the patient's constipation, pressure ulcers and depression (she's on antidepressants) are complications of her multiple sclerosis. I'm puzzled by her hypotension and anemia, however. It could be just related to her chronic disease. However, it's not our job to determine a medical diagnosis. We just deal with the symptoms. If you have a book of care plans or nursing diagnoses, it would be really helpful. I realized when I was looking at my NANDA reference on Constipation that your instructors had given you several of the defining characteristics of constipation in your scenario. So, your instructors are looking to see that you are getting this process on how to choose your nursing diagnosis down correctly. If not using a resource, one could very mistakenly think that this woman has a possible abdominal malignancy, especially with the EGD being ordered. Who knows why they are doing that? It may have just been a red herring.

You might want to go to a site like Medline Plus (http://www.medlineplus.gov/) to get information on multiple sclerosis and decubitus ulcers.

Good luck with your seminar!

[Jessy_RN]

Thanks Daytonite!!