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This is a discussion on CarePlan Chronic Bronchitis in Nursing Student Assistance, part of Nursing Student ... Im having difficulty with the 3 Nursing dx and related to factors. I've never had to do a full...by Legends777 Jan 3, '10Im having difficulty with the 3 Nursing dx and related to factors. I've never had to do a full care plan on my own and am hitting a wall.
59 yr M comes to ER complaining of worsening SOB and coughing up yellow sputum. Smoker, and truckdriver on the road all the time.
R-26 P-120 T-98.4 SaO2 88%ra.
wheezes and gurgles in chest, xray taken- not pneumonia.
finger tips brown and clubbed- sign of hypoxemia
WBC slightly elevated
RBC slightly elevated.
DR dx acute exacerbation of chronic bronchitis
Pt admitted to hospital
I've come up with Ineffective Airway clearance r/t bronchial secretion build up and bronchial inflammation????
Could Impaired Gas Exchange r/t hypoxemia be a dx???
Risk for infection r/t increased WBC ???
Any help or direction on how to organize and write out a careplan would be GREAT!!!
I had one 3 day rotation in a LTC and the careplans where pretty much computer generated and then adjusted to Pt, and even then I didnt get to actually see one done.
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- Jan 3, '10 by Daytonitebefore i go any further, you can also get information and examples on care planning on this thread: http://allnurses.com/general-nursing...ns-286986.html- help with care plans
basically, a care plan is a document that lists out the nursing problems that the patient has along with your strategies on what you are going to do about them. to diagnose, or determine the problems, you must first examine all the data. this is the same process that doctors, car mechanics , plumbers and other professionals go through when problem solving. for us nurses the data (information) that is important for us to examine and consider includes the following:
- a health history (review of systems)
- performing a physical exam
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
- medical diagnosis: acute exacerbation of chronic bronchitis (this is one of the copd's)
- worsening sob
- coughing up yellow sputum
- sao2 88% on room air
- wheezes and gurgles in chest
- finger tips brown and clubbed - sign of chronic hypoxemia
- wbc slightly elevated
- rbc slightly elevated.
from the data above you can diagnose:
- impaired gas exchange r/t alveolar-capillary membrane changes secondary to acute exacerbation of chronic bronchitis aeb sao2 of 88% on room air, respiratory rate of 26, pulse of 120 and worsening sob.
- ineffective airway clearance r/t secretion in bronchus and smoking aeb wheezes and gurgles in chest, productive cough of yellow sputum and worsening sob.
- ineffective health maintenance r/t lack of judgment (?) aeb continued smoking
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- care/perform/provide/assist (performing actual patient care)
- teach/educate/instruct/supervise (educating patient or caregiver)
- manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
- - - - - - - - - - - - - - -
im having difficulty with the 3 nursing dx and related to factors. i've never had to do a full care plan on my own and am hitting a wall.
the related to factors have to do with the cause of the nursing problem (your nursing diagnosis). it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.i've come up with ineffective airway clearance r/t bronchial secretion build up and bronchial inflammation????
yes this is correct. i'd just word it differently.could impaired gas exchange r/t hypoxemia be a dx???
yes, but hypoxemia is a more of a medical diagnosis. also, this nursing diagnosis specifically refers to gas exchange in the alveoli of the lungs. ask yourself why or what has happened to the alveoli so that gas exchange has gotten messed up. the alveoli are either:risk for infection r/t increased wbc ???
- clogged up with secretions, as in pneumonia
- or, damaged as in copd so that gas exchange is severely affected
depends on how increased the wbcs are. this is a chronic condition so the wbcs would be expected to be slightly elevated. i'm not saying this is a wrong diagnosis. you can use it. i would rather see the guy stop smoking if possible because that is an actual problem. infection is only a potential problem and low on the totem pole of problems.
- Jan 4, '10 by yellowfluffballOur school had us get Sparks and Taylor's Nursing Diagnosis Reference Manual, it's a great help it gives you multiple nursing diagnoses, with interventions, expected outcomes, etc
some diagnoses include:
activity intolerance r/t oxygen supply and demand
knowledge deficit r/t difficulty understanding disease process and its effects on self care
We always start careplan out with
(1) assessment data that shows why you choose nursing diagnosis
vital signs, objective data, subjective data (facial expressions, pain, etc)
(3)patient expected outcomes
Patient will have increased O2 above 92% by end of hospital stay
Patient will verbalize reasons why smoking is dangerous to health by end of hospital stay
monitor patient's vital signs every hour
monitor patient's lab values (mainly WBC, RBC) every day
(5)evaluation of patient outcomes
Patient outcome was not met because patient's O2 were unchanged by end of hospital stay
Patient outcome was met because by third hospital stay O2 increased to 95%.
Hope this helps
- Jan 7, '10 by weardemglovesImpaired gas exchange r/t bronchial inflammation AEB lung crackles per auscultation (if it's an exacerbation he should have them).
Ineffective airway clearance r/t chronic, persistant sputum exacerbated by and secondary to disease process AEB presence of productive sputum
Risk for infection r/t continual bronchial secretions AEB continuous, productive cough
**Emphysema is the other cause of COPD and does not cause impaired gas exchange r/t productive cough, but causes impaired gas exchange r/t entrapment of air r/t damaged/collapsed alveoli and "air trapping" in the lungs r/t that alveolar collapse.
You can find all the interventions and alter them to these diagnoses in your med/surg book r/t most diagnoses you find or information on the internet. It is not easy, but then again, I am not going to give you any other advice or diagnoses proofreading unless you put forth a large amount of effort on your part from now on. Good luck.