Nursing Diagnosis help

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Hi, I am trying to come up with three nursing diagnosis for my Patient. He suffers COPD and was admitted with an upper resp. tract infection. He tested positive for Cocaine and Opiates and also has HTN; I came up with one diagnosis :

-Ineffective airway clearance R/T excessive pulmonary secretions secondary to infection

Now I was trying to formulate one along those lines and was not sure if it was right;

-Impaired gas exchange R/T ....and I got stuck there. I am trying to put something saying that it is because of the infection and mucus but also because of his COPD.

The third one I wanted to focus on his drug abuse but was not sure if there even was a nursing diagnosis talking about that.

COuld you please help me? I am not asking anyone to do my homework ( I need to be able to figure it out on my own after all) but just to get some pointers to kinda guide me please.

Thank you so much for taking the time to read.

Stephanie :D

0 Votes
Specializes in Urgent Care.

Ineffective gas exchange r/t disease process

r/t poor perfusion

What kinds of s/s does he have related to the drug use?

Deficient knowledge?

Risk for injury?

I don't have a dx book in front of me.

0 Votes
Specializes in med/surg, telemetry, IV therapy, mgmt.

hi, stephanie!

well, part of the reason you are having trouble is because you are trying to match up nursing diagnoses with medical diagnoses and it just doesn't work that way!

the definition of impaired gas exchange is "excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane." (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 83) therefore, your patient will need to have signs and symptoms (defining characteristics) that support that. those signs and symptoms (defining characteristics) come from your assessment data (step #1 in the nursing process and care planning process). nanda lists some of the defining characteristics for this diagnosis as:

  • visual disturbances
  • decreased carbon dioxide
  • tachycardia
  • hypercapnia
  • restlessness
  • somnolence
  • irritability
  • hypoxia
  • confusion
  • dyspnea
  • abnormal arterial blood gases
  • cyanosis
  • abnormal skin color (pale, dusky)
  • hypoxemia
  • hypercarbia
  • headache upon awakening
  • abnormal rate, rhythm, depth of breathing
  • diaphoresis
  • abnormal arterial ph
  • nasal flaring

the "related to" factors you would use with your nursing diagnostic statement would be:

  • ventilation perfusion imbalance, or
  • alveolar-capillary membrane changes

if you know the pathophysiology of the patient's copd you can use alveolar-capillary membrane changes if you know from reading the doctor's documentation that this is true. otherwise, if you have abgs to support the impaired gas exchange problem, then you use ventilation perfusion imbalance as your "related to" factor. so, your final nursing diagnosis for this might look something like this: impaired gas exchange r/t ventilation perfusion imbalance secondary to chronic obstructive pulmonary disease and upper respiratory infection aeb abnormal blood gases, dyspnea, and restlessness. please notice that all the items following the words "aeb" are the actual symptoms, or assessment data, you will have obtained on the patient. this is an important concept for you to grasp. those become the "problems" that you are going to develop your nursing interventions for. those "problems" are the direct cause of what follows the words "r/t" in your diagnostic statement. do you see how these things must relate to each other? and, eventually, your goals and nursing interventions will relate back to the "problems". it all has to make rational sense. this is part of the critical thinking of nursing.

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=23

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_032.php

infection, technically, is a medical diagnosis. however, the symptoms of it are something that we nurses can do something about. so, if one of the manifestations of the infection is a fever, there is a nursing diagnosis for that and nursing interventions that can be done for it. with an upper respiratory tract infection, there is some teaching that needs to be done with respect to coughing and deep breathing. keeping the respiratory passages clear of mucus comes under the nursing diagnosis of ineffective airway clearance and it can be used along with impaired gas exchange. just make sure you keep your defining characteristics that go with each very clear and your nursing interventions that go with each confined to each. it is very easy to mix and merge these two nursing diagnoses together if you are not careful. the difference between the two is in what is causing the symptoms. with ineffective airway clearance, your cause is often an obstructed airway due to retained secretions or the presence of excessive mucus. so, you might also end up with a nursing diagnosis like this: ineffective airway clearance r/t excessive mucus in the bronchial passages secondary to upper respiratory infection aeb diminished breath sounds, rales and rhonchi, ineffective coughing and restlessness.

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=02

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_002.php

as for the drug abuse. . .what are the problems he is having as a result of the drug abuse? as nurses, we can only treat the problems the patient has resulting from the drug abuse, not the medical diagnosis of drug abuse. does that make sense to you? so, along comes this patient and he's got cocaine and opiates in his system. are they causing problems at this point? is he suffering any withdrawal? if so, what are the physical and psychological symptoms he's having due to the withdrawal? as nurses, we can develop nursing strategies to work on these symptoms (anxiety, difficulty sleeping, difficulty eating, dts, feelings of powerlessness, depression). are there social problems related to his personal relationship or job that need to be addressed? what has the patient said to you about any of these? those are also symptoms, or defining characteristics, that will lead you to specific nursing diagnoses.

i'm curious as to why you aren't addressing the hypertension and i'm betting that your instructor is going to ask the same thing. what drugs is this patient on for the hypertension? often the heart and lung problems are closely aligned. if he already has copd, he most likely has some major cardiac problems as well. a nursing diagnosis of decreased cardiac output is probably in order here. however, you need to know what kind of heart failure he has and what level of failure he has achieved in order to nail the correct type of output problem.

there is care plan writing help in these two threads on the nursing student forums that you might want to review.

if you are still having problems with this, please ask for more assistance. i do not believe that this is doing someone's homework for them. learning how to pick nursing diagnoses is very difficult to learn at first and i am always happy to help out students learn how to do this.

0 Votes

I can't add much, but I've had patients with COPD and they often suffer from anxiety r/t the disease process.

0 Votes
Specializes in ortho/neuro.

My instructor wants us to look at the patient holistically and think how the disease process/surgery/hospitalization affects the patients quality of life or prevents pt. from functioning.

With that in mind, you could use Activity intolerance R/T inadequate oxygenation, decreased stamina, etc. Ineffective health maintainence R/T illegal drug use and so on.

0 Votes
Specializes in LTC, home health, critical care, pulmonary nursing.
hi, stephanie!

well, part of the reason you are having trouble is because you are trying to match up nursing diagnoses with medical diagnoses and it just doesn't work that way!

the definition of impaired gas exchange is "excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane." (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 83) therefore, your patient will need to have signs and symptoms (defining characteristics) that support that. those signs and symptoms (defining characteristics) come from your assessment data (step #1 in the nursing process and care planning process). nanda lists some of the defining characteristics for this diagnosis as:

  • visual disturbances
  • decreased carbon dioxide
  • tachycardia
  • hypercapnia
  • restlessness
  • somnolence
  • irritability
  • hypoxia
  • confusion
  • dyspnea
  • abnormal arterial blood gases
  • cyanosis
  • abnormal skin color (pale, dusky)
  • hypoxemia
  • hypercarbia
  • headache upon awakening
  • abnormal rate, rhythm, depth of breathing
  • diaphoresis
  • abnormal arterial ph
  • nasal flaring

the "related to" factors you would use with your nursing diagnostic statement would be:

  • ventilation perfusion imbalance, or
  • alveolar-capillary membrane changes

if you know the pathophysiology of the patient's copd you can use alveolar-capillary membrane changes if you know from reading the doctor's documentation that this is true. otherwise, if you have abgs to support the impaired gas exchange problem, then you use ventilation perfusion imbalance as your "related to" factor. so, your final nursing diagnosis for this might look something like this: impaired gas exchange r/t ventilation perfusion imbalance secondary to chronic obstructive pulmonary disease and upper respiratory infection aeb abnormal blood gases, dyspnea, and restlessness. please notice that all the items following the words "aeb" are the actual symptoms, or assessment data, you will have obtained on the patient. this is an important concept for you to grasp. those become the "problems" that you are going to develop your nursing interventions for. those "problems" are the direct cause of what follows the words "r/t" in your diagnostic statement. do you see how these things must relate to each other? and, eventually, your goals and nursing interventions will relate back to the "problems". it all has to make rational sense. this is part of the critical thinking of nursing.

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=23

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_032.php

infection, technically, is a medical diagnosis. however, the symptoms of it are something that we nurses can do something about. so, if one of the manifestations of the infection is a fever, there is a nursing diagnosis for that and nursing interventions that can be done for it. with an upper respiratory tract infection, there is some teaching that needs to be done with respect to coughing and deep breathing. keeping the respiratory passages clear of mucus comes under the nursing diagnosis of ineffective airway clearance and it can be used along with impaired gas exchange. just make sure you keep your defining characteristics that go with each very clear and your nursing interventions that go with each confined to each. it is very easy to mix and merge these two nursing diagnoses together if you are not careful. the difference between the two is in what is causing the symptoms. with ineffective airway clearance, your cause is often an obstructed airway due to retained secretions or the presence of excessive mucus. so, you might also end up with a nursing diagnosis like this: ineffective airway clearance r/t excessive mucus in the bronchial passages secondary to upper respiratory infection aeb diminished breath sounds, rales and rhonchi, ineffective coughing and restlessness.

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=02

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_002.php

as for the drug abuse. . .what are the problems he is having as a result of the drug abuse? as nurses, we can only treat the problems the patient has resulting from the drug abuse, not the medical diagnosis of drug abuse. does that make sense to you? so, along comes this patient and he's got cocaine and opiates in his system. are they causing problems at this point? is he suffering any withdrawal? if so, what are the physical and psychological symptoms he's having due to the withdrawal? as nurses, we can develop nursing strategies to work on these symptoms (anxiety, difficulty sleeping, difficulty eating, dts, feelings of powerlessness, depression). are there social problems related to his personal relationship or job that need to be addressed? what has the patient said to you about any of these? those are also symptoms, or defining characteristics, that will lead you to specific nursing diagnoses.

i'm curious as to why you aren't addressing the hypertension and i'm betting that your instructor is going to ask the same thing. what drugs is this patient on for the hypertension? often the heart and lung problems are closely aligned. if he already has copd, he most likely has some major cardiac problems as well. a nursing diagnosis of decreased cardiac output is probably in order here. however, you need to know what kind of heart failure he has and what level of failure he has achieved in order to nail the correct type of output problem.

there is care plan writing help in these two threads on the nursing student forums that you might want to review.

if you are still having problems with this, please ask for more assistance. i do not believe that this is doing someone's homework for them. learning how to pick nursing diagnoses is very difficult to learn at first and i am always happy to help out students learn how to do this.

this is why i love this forum!

0 Votes
Specializes in med/surg, telemetry, IV therapy, mgmt.
my instructor wants us to look at the patient holistically and think how the disease process/surgery/hospitalization affects the patients quality of life or prevents pt. from functioning.

with that in mind, you could use activity intolerance r/t inadequate oxygenation, decreased stamina, etc. ineffective health maintenance r/t illegal drug use and so on.

activity intolerance: definition: "insufficient physiological or psychological energy to endure or complete required or desired daily activities." related factors (etiology): bed rest or immobility, generalized weakness, imbalance between oxygen supply and demand, sedentary lifestyle. defining characteristics (symptoms): verbal report of fatigue or weakness, abnormal heart rate or blood pressure response to activity, electrocardiographic changes reflecting arrhythmias or ischemia, exertional discomfort or dyspnea. (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 3)

is decreased stamina a cause of activity intolerance? or, a symptom?

not every nursing program is going to require that the patient be assessed holistically. that is something your nursing program wants its students to do. my nursing program had us assess patients based on their response to a number of environmental stressors. however, when you move to the step to determine nursing diagnoses you are taking the abnormal assessment data that you found and using it to determine nursing diagnoses. that doesn't change and it isn't significantly affected by the style of data collection assessment you used. you don't have to use nanda language when wording diagnostic statements if your instructors have directed you to do that. however, most nursing programs are asking students to follow nanda rules. the concept behind what goes into the nursing diagnostic statement never changes. it is:

problem--etiology--symptoms

example: problem: inactivity. etiology: imbalance between oxygen inspired and carbon dioxide expiration. symptoms: inability to walk from bed to bathroom without becoming fatigued and having to sit down, heart rate elevation to 120 and profuse sweating upon ambulating 10 feet, shortness of breath upon exertion. this evolves into a nursing diagnostic statement that can be written like this: activity intolerance r/t imbalance between oxygen supply and demand aeb inability to walk from bed to bathroom without becoming fatigued and having to sit down, heart rate elevation to 120 and profuse sweating upon ambulating 10 feet, and shortness of breath upon exertion.

there is method and rationale to this madness of writing care plans and nursing diagnoses.

0 Votes
Specializes in Infusion, Med/Surg/Tele, Outpatient.

Imbalanced nutrition: less than body requirements r/t COPD, cocaine use AEB pt's report of poor appetite, wt loss, not buying food, appears malnourished (skin/hair), low albumin, .....

Pt's with COPD are recommended to eat 6 small meals w/high protein d/t disease process - weight loss very common in end-stage, small meals b/c they tire easily when eating, consider dietary consult, recommend supplement

Pts with drug abuse often forego buying food in order to buy the drug

0 Votes
Specializes in ortho/neuro.

Daytonite~ thank you for you elaboration. I didn't mean for my post to be a full DX. I was just trying to point out a different perspective to consider when coming up w/ 3 or more nursing diagnosis for the same patient. I have found this approach helpful to broaden my 'field of vision' so to speak on addressing patient issues. I am not implying to not use "inefective airway clearance, etc'., but that this is a nice supplement to use with them. I also didn't elaborate on R/T and AEB because I was unsure of what specific data was available for this patient such as statements of feeling weak after ambulation, etc.

I do appreciate all your information, and didn't mean to come across like I was not agreeing with your post or your rationale as I am nowhere near an expert at careplans. I only wanted to provide what has worked for me and as a different way for the OP to perhaps go at the DX when struggling with coming up w/ multiple for the same pt.

0 Votes
Specializes in med/surg, telemetry, IV therapy, mgmt.
imbalanced nutrition: less than body requirements r/t copd, cocaine use aeb pt's report of poor appetite, wt loss, not buying food, appears malnourished (skin/hair), low albumin, .....

pt's with copd are recommended to eat 6 small meals w/high protein d/t disease process - weight loss very common in end-stage, small meals b/c they tire easily when eating, consider dietary consult, recommend supplement

pts with drug abuse often forego buying food in order to buy the drug

while what you are saying about copders and long term drug abusers is true i want to point out that that your language in the nursing diagnostic statement [imbalanced nutrition: less than body requirements r/t copd, cocaine use aeb pt's report of poor appetite, wt loss, not buying food, appears malnourished (skin/hair), low albumin] would be found incorrect by many nursing instructors for these reasons: (1) the etiology section of this diagnostic statement is indicating two medical determinations as the cause of the inadequate food intake, and (2) there are etiologies mixed in with assessment data items in the aeb items.

this particular nursing diagnosis pertains to "intake of nutrients insufficient to meet metabolic needs." (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 126) appropriate related factors (r/t) that fit this descriptor: "inability to ingest or digest food or absorb nutrients due to biological, psychological, or economic factors." to say "copd, cocaine use" tells nothing of the cause behind the inadequate nutrient intake. more appropriate "r/t"s would be such things as inability or failure to eat due to loss of appetite, lack of financial means to purchase food, or failure to purchase food. these are things included in the aeb items that need to pulled out and placed in their correct place in the diagnostic statement.

i want to look at the aebs (defining characteristics or symptoms) you attach to this nursing diagnosis:

  • patient's report of poor appetite
  • weight loss
  • not buying food
  • appears malnourished (skin/hair)
  • low albumin

i have to ask myself, how do each of these help to explain more fully, or effect, the cause of the problem. copd and cocaine use. the answer is, they don't. some of them are symptoms and some of them are causes of the nutrition problem. however, if you rewrite this nursing diagnosis and say: imbalanced nutrition: less than body requirements r/t failure to eat due to loss of appetite and failure to purchase food aeb weight loss, appears malnourished (skin/hair), and low albumin, you now have supported your aeb items with some specific logical reasoning. the weight loss, malnourished appearance and low albumin all describe a result, or effect, of (1) failure to eat due to loss of appetite, and (2) failure to purchase food. [note: some schools will permit students to include medical diagnoses and write their nursing diagnostic statements this way: imbalanced nutrition: less than body requirements r/t failure to eat due to loss of appetite and failure to purchase food secondary to copd and cocaine abuse aeb weight loss, appears malnourished (skin/hair), and low albumin]

another way to break this down is to think of the diagnostic statement as representing the following:

problem--etiology--symptoms

problem: not eating enough

etiology: no appetite, doesn't buy food

symptoms: weight loss, malnourished appearance, low albumin (abnormal data assessment items)

problem becomes the nursing diagnosis.

etiology becomes the r/t, or related factors, part of the diagnostic statement.

symptoms become the aeb, or defining characteristics, part of the diagnostic statement.

when you are first learning to work with nursing diagnoses, it is important that you have a nursing diagnosis reference book to help you understand the definitions, etiologies and symptoms of each one of the diagnoses so you can formulate these diagnostic statements correctly. one very important thing that makes nursing diagnoses different from medical diagnoses is that nursing diagnoses are based on a person's response and behavior to what is happening to them. in writing nursing diagnosis statements we are trying to stay with basic facts and not move too far into the realm of decision making with determining these patient problems because that takes us into the domain of medicine and the doctor's world. our decision-making expertise comes in the next step of the nursing care process: independent nursing interventions. and that is where we shine!

0 Votes
Specializes in med/surg, telemetry, IV therapy, mgmt.
Daytonite~ thank you for you elaboration. I didn't mean for my post to be a full DX. I was just trying to point out a different perspective to consider when coming up w/ 3 or more nursing diagnosis for the same patient. I have found this approach helpful to broaden my 'field of vision' so to speak on addressing patient issues. I am not implying to not use "inefective airway clearance, etc'., but that this is a nice supplement to use with them. I also didn't elaborate on R/T and AEB because I was unsure of what specific data was available for this patient such as statements of feeling weak after ambulation, etc.

I do appreciate all your information, and didn't mean to come across like I was not agreeing with your post or your rationale as I am nowhere near an expert at careplans. I only wanted to provide what has worked for me and as a different way for the OP to perhaps go at the DX when struggling with coming up w/ multiple for the same pt.

You want to talk about assessment and the OP wants to determine nursing diagnoses. OK, lets talk about assessment for the moment.

A style, or perspective, in doing an assessment is just that. Many roads lead to the same destination whether the patient is assessed by ADLs, functional needs, holistically or whatever stressors in their environment are impacting their behavior. When it's time to sit down and determine a nursing diagnosis, the assessment phase is completed. It is now time to look at abnormal data that was obtained during the assessment and determine the patient's problems.

What I find is that people overlook very basic things during their assessment process. This happens partly because of inexperience in assessing and partly because of lack of knowledge about the disease process going on or lack of knowledge about the assessment style they're supposed to be using and what the normal parameters should be so they can recognize the abnormal ones. When students sit down to start writing their care plans and say, "I don't know where to start", it's because:

  1. they don't know or understand the nursing process and that it proceeds in an orderly fashion from assessment to determination of the patients problems to the planning of their care to implementation of the plan to evaluation of the plan and back around through the entire process again
  2. they didn't do a thorough job of assessment to begin with

Hopefully, these improve with time, experience and learning from prior mistakes.

Now, back to nursing diagnosis, which is step 2 of the nursing process and what this thread was originally about. The only thing to consider when coming up with nursing diagnoses for a patient is:

abnormal data that was obtained during the assessment process = patient problems

It is that simple. There is nothing any more complex about it. The difficulties most have are that they missed picking up on important data, they have data but don't recognize it as "problems" or know what to do with it, or they are matching the data they do have with the wrong nursing diagnoses.

0 Votes
Specializes in ortho/neuro.

I don't understand where it seems I am talking about doing assessments, I meant to use the data you have collected, find what is abnormal, and apply that data to how it is holistically affecting the patients abilities to function in order to put it together and come up with a DX. For example, I had a pt. w/ COPD and my DX was activity intolerance R/T generalized weakness, decreased oxygen carrying capability of blood, imbalance between oxygen supply and demand AEB pt. verbalization of 'decreased energy and feeling weak', Hgb 11.1, pt. Sa02 levels 88% on RA during amulation and COPD.

0 Votes
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