Nursing Students General Students
Published Nov 11, 2004
shel_wny
336 Posts
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?
Shel
manna, BSN, RN
2,038 Posts
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! :)
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!
Aneroo, LPN
1,518 Posts
Other goodies:
-(risk for) impaired tissue perfusion
-(risk for) fluid volume excess
-decreased cardiac output r/t CHF disease process