Question about Care Plans

Nursing Students General Students

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Specializes in Critical Care / Psychiatry.

Do Nursing Diagnoses take history into mind?

For example, my client came to the hospital weak and SOB probably from his CHF but now he is completely fine with a SaO2 94% on Room Air. No distress or shallow/labored breathing. Do I still formulate a Nursing Diagnosis for the respiratory system as Impaired gas exchange? Or, do I simply state that he has no respiratory issues since those were at his admission and have been resolved by now.

Any suggestions? :uhoh3: :eek:

Shel

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How about risk for impaired gas exchange?

I don't think that using things done in the past would work (unless you've been caring for him since he was admitted) - since it's no longer an issue, you wouldn't really have any relevant goals/interventions. If you did the risk for, though - you could focus on maintaining his gas exchange at its current level. I've been told that your nursing dx has to be either a current or potential ("risk for") problem.

Good luck! :)

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Specializes in Critical Care / Psychiatry.
How about risk for impaired gas exchange?

I don't think that using things done in the past would work (unless you've been caring for him since he was admitted) - since it's no longer an issue, you wouldn't really have any relevant goals/interventions. If you did the risk for, though - you could focus on maintaining his gas exchange at its current level. I've been told that your nursing dx has to be either a current or potential ("risk for") problem.

Good luck! :)

Good thinkin! Thanks!

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Specializes in Cath Lab, OR, CPHN/SN, ER.

Other goodies:

-(risk for) impaired tissue perfusion

-(risk for) fluid volume excess

-decreased cardiac output r/t CHF disease process

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