i'd like to know what medications and labs have been done for this patient. the medications will give you an idea of what he is being treated for as well. his medical diagnoses include:
- coronary artery disease
- congestive heart failure
- acute renal failure
- non-small cell ca
the thoracentesis was done to remove fluid from the pleural space. it is not uncommon for people with ca of the lung to develop fluid in the pleural space that needs removal. i would look for cytology and culture of the fluid to have been done as well. you know he has some kind of infection going on in his respiratory track since he has a positive sputum for e.coli. it's possible he has pneumonia. pneumonia can be a post-op complication of heart or lung surgery. he's having oxygenation problems as shown by his abg results. the rhonchi in his lungs can be indicative of pneumonia or his chf.
i would start by reviewing the pathophysiology, signs and symptoms for the medical diagnoses this patient has. you need to have an understanding of them. you are correct. for such a complex patient, you are missing a lot of data. you are going to find some signs and symptoms there when you do your your own assessment of this patient. your nursing diagnoses always have to grow out of, or develop, from symptoms the patient is having. those symptoms may be objective or subjective. i like to use family practice notebook at this site: http://www.fpnotebook.com/index.htm
to get nicely listed signs and symptoms of medical diseases. those same signs and symptoms, if you also observed them, can be used as the basis to form your nursing diagnoses. use the search box at the top left of every page of family practice notebook to search for medical diagnoses. compare the signs and symptoms they list for all his various medical diseases with the data you collected and see if there aren't things that you overlooked in your data collection and assessment.
you use a diagnosis such as ineffective airway clearance
when the patient is having trouble getting sputum cleared out of his airway (isn't coughing effectively). the need for oxygen and low oxygen saturation are not defining characteristics of this diagnosis. the presence of bilateral rhonchi may
be, but it would also be good to have data showing the patient is coughing ineffectively or coughing up a lot of sputum but still not getting his airway cleared. an alternative nursing diagnosis would be ineffective breathing pattern
if the patient's cancer has spread to the point of his lungs just not having enough capacity to do the job for him. however, the patient would be having all kinds of dyspnea, shortness of breath and obvious signs of difficulty breathing in order to use this nursing diagnosis. the low oxygen saturation is suggestive of impaired gas exchange
and would also include the symptom of rhonchi, the need for oxygen, and the fact that he had a revascularization procedure. with coronary heart disease, chf and hypertension, this patient also is likely to warrant a nursing diagnosis of decreased cardiac output
. this patient has a lot of heart and lung issues going on because of primary disease to the heart (cad) and lung (cancer), surgical intervention (the heart surgery) and now post-op complications, respiratory infection with e-coli and chf. these are big time problems. on top of all that he's got diabetes which is sending up red flags with me that might be somehow related to his acute renal failure, hypertension, and anemia.
do you have a care plan or nursing diagnosis book
to help you out here? i am suggesting that you go back and look at the descriptions of the medical diseases this patient has. add the data that you collect today to that. then, revise your list of abnormal data before you begin grouping the symptoms into potential nursing diagnoses again. you can use whatever abnormal data you have in more than one nursing diagnosis as the aeb items. post again to this thread if you still need more guidance. this is going to end up being a huge care plan for a patient with many problems. did you pick this patient, or was the patient assigned to you?