Diagnoses--am I on the right track?

[Megsd, BSN, RN]

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.

[Daytonite, BSN, RN]

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
  
• hypertension
  
• diabetes
  
• anemia

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?

[Megsd, BSN, RN]

My patient was assigned for me. I don't have to do a complete care plan, just come up with my number one priority diagnosis and my interventions are based on that. This is my second week (ever) of clinical, so I'm not doing a whole lot of actual "nursing stuff" yet.

I did buy a nursing diagnosis/care plan book yesterday that was helpful, but because I was uncertain about the medical cause of his respiratory issues, I wasn't sure which section of the book to look in.

Of course, things change from day to day. Today in his assessment he initially had bilateral course rhonchi, but after respiratory therapy came to see him, his lungs were clear. He had dyspnea upon exertion and a low SpO2 (91%) still. His family was just informed today about the cytology (I guess they're doing additional testing next week to confirm), I'm not sure if he knows yet. Good thought on the decreased cardiac output... I hadn't thought much about that, but it makes a lot of sense with all the diseases and complications and procedures he's undergone.

He's really a great patient to learn a lot from, but 3 weeks into nursing school he's a little more complicated than I would like. Hopefully as I get more experience I can look back on this one and understand a bit more about what's going on.

Thanks for the response and the link... I will bookmark that one!

[Daytonite, BSN, RN]

wow! only your second week of clinical! this is a patient with a lot of stuff going on. the top nursing diagnoses for this patient are going to be cardiac and respiratory related. there is going to be cross-over between the symptoms used to support these diagnoses as well--which is ok. there are also going to be teaching issues and emotional support issues related to the surgery, his heart and now, the cancer. tell me he's a smoker and hasn't quit yet, because that will be another issue.

i want you to read the beginning sections of that care plan book you bought yesterday. and, periodically, as you are going through nursing school, read it. it will talk about the nursing process. it should also tell you how the written plan of care is developed from the nursing process. everything begins with assessment and data collection. this process never stops and is ongoing. abnormal data is used to pick, and also become the supporting evidence for, your nursing diagnoses. that abnormal data also become the focus of your nursing interventions. and, of course, for your instructors, you will need to supply rationales for all the interventions you list. in the old days when i was going through nursing school we didn't use nursing diagnosis. we just listed patient's symptoms, what are today called abnormal data, or defining characteristics (that's nanda terminology), one by one and nursing interventions for each. what nanda has done has been to group abnormal data, or defining characteristics, and put labels on them called nursing diagnoses.

here are threads on the nursing student forums that have a lot of information in them that you should take some time to read. you may find some helpful information or explanations in them. don't hesitate to post questions. i'm always looking for questions from students about care plans and nursing diagnoses. i try to get online at least once a day to help out, so don't expect quick answers from me. i also have dial up service which is slow and there are certain times of the day that i get disconnected on a regular basis.

https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)

https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)

https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)