I'm doing clinicals on a cardiac/telemetry unit this quarter, and my patient to care for tomorrow is very complicated. I have done all my chart research, looked up the meds and labs, but I am having a difficult time with the diagnoses because I can't figure out why he's having this problem. Here's my patient in a nutshell:
77 yr old male, admitted with chest pain and CAD, underwent myocardial revascularization and post-op was diagnosed with CHF, acute renal failure, and non-small cell carcinoma. They did a thoracentesis (but no mention in charts of why, no effusion, pneumothorax, etc.) and a sputum sample (heavy growth of E. coli). His ABG showed a low PO2 and low SpO2. He has bilateral rhonchi and is on oxygen via nasal cannula. He also has a hx of hypertension and diabetes, and is anemic.
I think my priority nursing diagnosis is ineffective airway clearance AEB low oxygen saturation, need for oxygen via cannula, rhonchi, sputum.
But since there is no mention of WHY he is having respiratory issues, I am having a hard time coming up with the "related to" part of the diagnosis. While I would like to say it's due to the bacterial growth in his sputum, I'm not confident enough to use "infection" or "lung congestion" as my etiology. His impaired oxygenation could also be due to his anemia, or maybe edema from CHF, but I feel like there's more going on. I feel like if I had a more complete medical diagnosis I would be able to make a more accurate nursing diagnosis.
Should this more complete diagnosis be in the chart (maybe it was there and I misread the physicians' handwriting), or do I really even NEED to know the "why" behind his respiratory issues in order to plan my interventions?
Thanks in advance for the help.