Can you help me with my nursing diagnosis?

  1. I need to do a care plan related to RESPIRATORY. The patient I had was a 69 yo female. Her diagnosis was sepsis, UTI, anemia, COPD, and lung cancer. She also has psychosis with paranoid personality trait, confused, and agitated. She was not on nasal cannula, just room air. She coughed occasionally, and sounded productive. She had a high fever which was not going down and they were trying to find the reason behind it. it could be the uti or sepsis. I had to help her eat her food because she wasn't eating. on the 2nd day, she was very lethargic and her dentures were very loose. i fed her once and she barely chewed her food so i stopped feeding her. I took off her dentures.
    Her lung and heart sounds were clear, confirmed by the nurse.

    I honestly do not know where to start because she has a lot of things going on. I think her psychosis is important, but how do I incorporate that into a respiratory diagnosis?
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    About starrys

    Joined: Oct '11; Posts: 21; Likes: 2


  3. by   SuesquatchRN
    Quote from starrys
    I think her psychosis is important, but how do I incorporate that into a respiratory diagnosis?

    You don't. You work with respiratory and only respiratory. Psychosis would be a separate dx and series of interventions.

    Keep it simple.
  4. by   Double-Helix
    Your patient has COPD, which means that she has a chronic lung disease. Even though that disease might not be the biggest of her problems at the moment, it's still a big factor in her health. She also has lung cancer, which seriously affects respiratory function.

    Look up the characteristics of COPD and how lung cancer affects the lung tissue and lung function. Then you should find it pretty easy to choose a respiratory related nursing diagnosis.
  5. by   traumaRUs
    Moving to nursing student assistance.
  6. by   Pacs, RN
    I agree with my colleagues. Remember that we always give priority to the airway, breathing and circulation (ABC) above all else as these are necessary functions needed for life. All the other problems (potential and foreseeable) like that of psychosis are secondary.

    Like SuesquatchRN said, if you wish to address the problem of psychosis, make a separate nursing diagnosis for that particular problem. Otherwise, focus your attention on your respiratory diagnosis and ignore all else.