i do not pretend to understand this cpne stuff, but i do understand the nanda construction of nursing diagnoses and critical thinking.
ineffective airway clearance r/t (admitting diagnosis) aeb abnormal breath sounds
outcome: pt will maintain a patent airway at all times.
interventions: 1.) assess lung sounds
2.) ask pt to perform deep breathing and coughing exercises
rationale: a patent airway is a physiological need. without a patent airway, it may interfere with the pt's ability to perform adl's, progress towards healing, and pt's participation in treatment plan.
the related factor of your diagnostic statement can never be a medical diagnosis. the nanda taxonomy gives a good listing of what your related factors (etiologies) can be for this diagnosis. if you have a cpne guideline for this diagnosis, use it. or, the appendix of taber's cyclopedic medical dictionary includes the nanda taxonomy information for the nursing diagnoses.musculoskeletal management
impaired physical mobility r/t musculoskeletal impairment aeb limited range of motion
outcome: pt will increase physical activity
interventions: 1.) assess pt's mobility status
2.) perform passive or active rom on designated extremities
rationale: mobility is a physiological need. without adequate mobility, it may interfere with pt's ability to perform adl's, progress towards healing, and pt's participation in treatment plan.
the patent airway being a physiological need, performing adls, progress toward healing and patient's participation in a healing plan are not valid rationales for nursing interventions. rationales are the reason why you are doing a specific intervention.
the rationale (reason) for assessing lung sounds is to evaluate the effectiveness of the patient's coughing efforts. the lungs change constantly, so lung assessment needs to be done all the time.
i wouldn't "ask" the patient to perform deep breathing and coughing exercises without instructing them in how to do them first.
the rationale (reason) for doing deep breathing and coughing is that it increases the volume of air in the lungs and promotes the expulsion of secretions. (do not forget that the title of this diagnosis is ineffective airway clearance which is defined as the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway [page 308, nanda-i nursing diagnoses: definitions & classification 2007-2008])
the first intervention of assess pt's mobility status is invalid. in order to have diagnosed this problem of impaired physical mobility, the patient's mobility status would have to have been assessed to come to the conclusion that there was a physical mobility problem.risk for injury r/t impaired mobility
outcome: pt will be free from injury during pcs
interventions: 1.) call light within reach when pt is left unattended
2.) bed in low position when pt is left unattended
rationale: safety is a physical and physiological need. pt need to be free from injury in order to progress towards treatment goals, and be able to perform adl's as independently as possible.
your rationales are all wrong.
the rationale (reason) for performing active and passive rom is that it helps maintain the integrity of joint function and helps maintain or increase muscle strength.
activity intolerance r/t (admitting diagnosis) aeb exertional dyspnea.
outcome: pt will participate in activity without experiencing dyspnea.
interventions: 1.) assess pt's response to activity
2.) provide frequent rest periods
rationale: being able to tolerate activity is a physiological need. if the pt is able to tolerate activity without dyspnea, he/she will be able to fully participate in his plan of care and his risk for respiratory problems will be decreased.
if the only cause (risk) for injury is impaired mobility
then i would not even use this diagnosis since impaired mobility
is another nursing diagnosis. just use impaired physical mobility
the outcome is not to have any injury occur during pcs.
why do we put a call bell within reach of a patient when they are going to be left unattended?
rationale: putting a call bell in reach of the patient is so they can use it to call for assistance.
why are beds left in their lowest position when patients are left in them unattended?
rationale: a low bed position is easier for the patient to get in and out of bed.
the related factor of your diagnostic statement can never be a medical diagnosis.pain management
acute pain r/t (admitting diagnosis) aeb pt rating pain (#) on a scale of 1-10.
outcome: pt will report pain management regimen relieves pain to a satisfactory level of 3 or less on a scale of 1-10.
interventions: 1.)assess pt's level of pain
2.) report pt's level of pain to the primary nurse
rationale: freedom of pain is a physiological need. without freedom of pain, it may interfere with pt's ability to perform adl's, progress towards healing, and pt's participation in treatment plan.
the first intervention of assess pt's response to activity is invalid. in order to have diagnosed this problem of activity intolerance, the patient would have to have been assessed to come to the conclusion that there was a activity intolerance problem. you don't diagnose this problem and then continually assess for it.
your rationales are all wrong.
rationale (reason) for provide frequent rest periods is that providing rest periods allows the patient to have periods of time of low energy expenditure as well as time to recuperate.
the related factor of pain is always something that causes injury and can never be a medical diagnosis.
rationale (reason) for assessing the patient's level of pain is to establish a baseline objective measure of the patient's subjective experience of pain [otherwise how will you be able to know if they are experiencing pain relief later after pain medication has been given?]
rationale (reason) for report pt's level of pain to the primary nurse is, i assume, because she is the one who gives pain medication? this is passing the buck, dude! even as an lpn who can't give pain medication there are things you can do to help the patient relieve their pain such as reposition the patient, give them a back massage, use short, simple relaxation exercises to distract them, dim the lights in the room and keep noise down, or play soft, soothing music.