I need help with a nursing diagnosis for my careplan PLEASE : (

  1. Hi allnurses,

    My careplan is due Monday the 16 of Feb., and I am havind trouble finding the right diagnoses for my client.

    He is a 64 y-o male who presented with dyspnea (Shortness of breath)and leukocytosis.

    He has a hx of: COPD, Smoking 1pk/day, Asthma-uses CPAP at night, hypertension, and Type 2 diabetes. He wears dentures. He also has Hx of a abd hernia repair. (unrelated to this visit)

    I need three nursing diagnosis and tX plans, but I looked in mu Nursing diagnosis book, and I cannot find a Nurs. Dx of impaired gas exchange (do they not use this?) I see Ineffective Airway Clearance (not being able to cough out excess mucous, but I was kinda hoping for something better than just Can't cough up mucous to get it out.

    Pt is also obese w a wt of 249 and ht of 5'10" .
    As a second Nursing Dx. I chose imbalanced nutrition: more than body requirements R/t wt . & decreased activity.

    I also need a Psychosocial Dx.

    Can anyone give me some recomendations?:bowingpur

    Thanks in Advance,

  2. 4 Comments

  3. by   NSALVADORE
    for the psychosocial, activity intolerance and for the physiological yes impaired gas exchange is used as far as I know, it is a Nanda approved dx! Good luck!
  4. by   Daytonite
    diagnosing is based on the signs and symptoms that the patient has. these come from the assessment that was done. the only symptoms that you've given about this person are:
    • dyspnea - this is a component of several nursing diagnoses so more respiratory assessment is needed
    • decreased activity - this needs more specific clarification
    with copd and asthma i would expect this patient to have adventitious lung sounds, abnormal abgs, some coughing, sputum production, elevations in heart and breathing as well as b/p with activity. with diabetes and obesity i would look for abnormal blood sugars and evidence that the patient doesn't eat the right diet. is there any evidence of complications of the diabetes? can his hypertension be linked to heart disease or cad which is a complication of diabetes? does he have any edema? what is this leukocytosis about? does he have an infection? chronic bronchitis, perhaps, because of his smoking?

    you cannot use any nursing diagnosis unless there is evidence to support it. a detective doesn't arrest someone for murder unless they have evidence that indicates the suspect probably did it. likewise, you can't assign a diagnosis to someone without evidence indicating the problem exists. nanda publishes a definition, defining characteristics (signs and symptoms) and related factors for each diagnosis. this is called the taxonomy. this information should be listed in the care plan book you are using, but if it is not you can find this information:

    ineffective airway clearance
    this diagnosis is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. it is used with copd and asthma when patients have dyspnea and adventitious lung sounds which are indicative of retained secretions. active smokers are always producing and hacking up sputum, so this is an appropriate diagnosis to use.
    imbalanced nutrition: more than body requirements r/t wt . & decreased activity
    this is constructed incorrectly. the related factor (cause, etiology) of this problem must be what causes an excessive intake of food. "weight" or being obese is not the cause of eating too much. neither is decreased activity. decreased activity, however, is evidence of the problem. see: http://www1.us.elsevierhealth.com/me...ex.cfm?plan=38 and imbalanced nutrition: more than body requirements
    need a psychosocial dx
    there is no assessment evidence that points to a psychosocial problem. smoking, if the patient will not quit, is a risk-prone health behavior, but you need evidence to support using it. if he is willing to quit, then, deficient knowledge, smoking cessation can be used.
  5. by   Daytonite
    Quote from nsalvadore
    for the psychosocial, activity intolerance and for the physiological yes impaired gas exchange is used as far as i know, it is a nanda approved dx! good luck!
    alert! activity intolerance is not a psychosocial diagnosis! it is a physiological diagnosis that is classified with cardiovascular/pulmonary responses in the activity/rest domain. it's signs and symptoms have no relationship with psychological or social behavior. all signs and symptoms of this diagnosis have to do with heart and respiratory changes, blood pressure changes, ekg changes, dyspnea, and fatigue with movement. definition: insufficient physiological pr psychological energy to endure or complete required or desired daily activities. don't let the words "psychological energy" in the definition fool you.
  6. by   DanEMT
    Call it what it is... obesity R/T excessive caloric intake. I f you can't use obesity try BMI (insert number here) R/t excessive caloric intake. usefull Dx unless metabolic mediated