First Case Study! Please Help.

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    hi all,

    i am a new nursing student and new to this site. i am working on my first case study, and i am having a hard time deciding on the diagnosis. i know i am close, but i am such a perfectionist that my uncetainty is driving me nuts. i can not make a decision unless i am absolutely sure. i have spent countless hours on this trying to decide, so needless to say my time-managment is not going well. i will take any help i can get. the case is as follows:

    case scenario

    “i can’t breathe.” morrie gasped for breath. “help me.”morrie looked up at you, his nurse, with eyes filled with fear. he raised thehead of the bed farther with the control and continued to gasp for breath. youcould feel your own anxiety increasing; it felt like morrie’s anxiety wascontagious. you pushed the overbed table so morrie could lean forward on it,sat on his bed, and worked with him to do pursed lip breathing and slow hisbreathing. you have given him all the medications that he could have. and youprayed he would get better.


    nursing assessment

    morrie has chronic obstructive pulmonary disease (copd).he has been suffering for
    5 years and is frequently a client on the respiratorynursing unit. he stopped smoking once diagnosed, but unfortunately still has significantlung disease. his vital signs are: 180/92-100.2-116, 28. his lungsounds are wheezing, with loud crackles throughout. the oxygensaturation is 84. he has oxygen per venture mask. his toes and fingersare cyanotic, as well as his oral mucous membranes.

    based on this information i grouped the significant symtoms and with the help of my nursing diagnosis handbook, came up with the possible diagnosises of ineffective airway clearance, imparied gas exchange, and ineffective breathing patterns. after that i am asked to give a complete diagnosis with the "related to" and "aeb". i can not decide whether to use impaired gas exchange r/t ventilation-perfusioninequality aeb abnormal breathing, cyanosis, tachycardia, hypoxemia, anddyspnea, or ineffective airway clearance r/t hyperplasia of the bronchial walls and asthma aeb adventitous breath sounds, cyanosis, and dyspnea.

    i realize that both might apply to the patient, but i need to pick the one that is most accurate/ more serious. which diagnosis is it most likely to be with the senerio?


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  3. 12 Comments so far...

  4. 2
    based on this information i grouped the significant symtoms and with the help of my nursing diagnosis handbook, came up with the possible diagnosises of ineffective airway clearance, imparied gas exchange, and ineffective breathing patterns. after that i am asked to give a complete diagnosis with the "related to" and "aeb". i can not decide whether to use impaired gas exchange r/t ventilation-perfusioninequality aeb abnormal breathing, cyanosis, tachycardia, hypoxemia, anddyspnea, or ineffective airway clearance r/t hyperplasia of the bronchial walls and asthma aeb adventitous breath sounds, cyanosis, and dyspnea.

    i realize that both might apply to the patient, but i need to pick the one that is most accurate/ more serious. which diagnosis is it most likely to be with the senerio?



    first, i want to say congratulations on starting your program! i am just a few weeks away from wrapping up my first year already, and i can't believe how fast it has gone.

    secondly, case studies are *hard*. they are time-consuming, and can seem quite tricky until you get the hang of them. i imagine that the "rules" are different from school to school, but it sounds to me like you have good handle on what they are looking for. i am thinking that either impaired gas exchange or ineffective airway clearance r/t copd as evidenced by (s/s) might be your best bet. i have found that our instructors haven't necessarily been looking for a specific answer. they just want to see that you are using the right line of thinking and covering your bases.

    i just kind of skimmed the info you gave, but i am curious about the "hyperplasia of the bronchial walls". it may very well be correct, but where did you get that information? (sorry if i missed it!)

    good job showing the work you have done. while i may not be the most helpful person to respond, i know you will find fellow nursing students/nurses much more willing to help when you show the work you have done when asking for help (and you're totally on the right track as far as i can see!)


    nickos
    sandanrnstudent and lala1016 like this.
  5. 2
    let's see here. your diagnosis is, "i think my patient has this diagnosis."

    "related to" means, "caused by/because he has this disease, condition, or pathology." yes, you may use a medical diagnosis as part of your rationale. however, you can never use a medical diagnosis alone for a nursing diagnosis-- you need your own assessment data for that (in this case, assessment data have been given to you).

    "as evidenced by" means, "these are the symptoms i observed/can document from the chart that support my decision." they are the evidence that your diagnosis is correct.

    so, let's see if we can neaten this up for you.

    based on this information i grouped the significant symptoms and with the help of my nursing diagnosis handbook, came up with the possible diagnoses of ineffective airway clearance,impaired gas exchange, and ineffective breathing patterns. after that i am asked to give a complete diagnosis with the "related to" and "aeb". i can not decide whether to use impaired gas exchange r/t ventilation-perfusion inequality aeb abnormal breathing, cyanosis, tachycardia, hypoxemia, and dyspnea,

    "i think my patient has impaired gas exchange because he is having a copd exacerbation. i know this because he is breathing rapidly, but has a very low peripheral oxygen saturation despite oxygen supplementation via venturi mask (indicates poor oxygen transport across the alveolar membrane), central (oral) and peripheral cyanosis (ditto), wheezing (indicating tight/restricted airways, from copd and repeated infection), tachycardia (from low o2), and dyspnea (from tight chest, increased work of breathing with no real result)." (all signs of poor oxygenation d/t lousy alveoli)(do not say "lousy" in your homework
    :d)

    does that make sense?


    or ineffective airway clearance r/t hyperplasia of the bronchial walls and asthma aeb adventitous breath sounds, cyanosis, and dyspnea.


    i think my patient has ineffective airway clearance, because he has a history of respiratory infections and signs of current infection. i know this because .... well, what do you make of this one? my nanda-i 2012-2014 says the defining characteristics of this nursing diagnosis can include absent cough, adventitious sounds, change in rate and rhythm, cyanosis, difficulty talking, dyspnea, excessive sputum, ineffective cough, orthopnea, restlessness, wide-eyed. i will leave it to you to read the related factors, of which he has several, too.

    i'm personally leaning towards the first diagnosis, because it's the most serious-- he's already in a deep hole with very low levels of oxygen to support all the hard work he's doing, and he's going to run out of gas (little pun there) and crash really soon.

    sandanrnstudent and lala1016 like this.
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    Thank you so much. I think I am going to go with the Impaired Gas Exchange. As far as the "hyperplasia of the bronchial walls," I got that from my book. I am not absolutely sure it is correct for this patient myself. That is something I would have confirmed before using it.
    nickos likes this.
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    Thank you so much! That was really helpful!
    nickos and GrnTea like this.
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    you're welcome. when we are helpful, we really appreciate the acknowledgment.
    sandanrnstudent and lala1016 like this.
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    As I am writing the case study I am still torn. I think the client has Impaired Gas Exchange r/t ventilation-perfusion inequality aebabnormal breathing, cyanosis, tachycardia, hypoxemia, and dyspnea, but I also think the patient has Ineffective Airway Clearance r/t COPD aeb crackling and wheezing lung sounds and cyanosis. But which one should I start intervening on first?
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    "you have given him all the medications he could have" seams really weird to me. All the COPD pts on the resp floor i was on for clinical had PRN nebs. Why does he not have one going? Does your school consider "praying he will get better" a nursing intervention? Why has a resp rapid response not been called yet?

    Anyone else think this Case Study is really wonkey?
  11. 2
    "as i am writing the case study i am still torn. i think the client has impaired gas exchange r/t ventilation-perfusion inequality aebabnormal breathing, cyanosis, tachycardia, hypoxemia, and dyspnea, but i also think the patient has ineffective airway clearance r/t copd aeb crackling and wheezing lung sounds and cyanosis. but which one should i start intervening on first? "

    where's your evidence for a v/q (ventilation/perfusion) inequality? you don't mention any, and absent a very specific exam (v/q scan) you won't have any.

    look at your nanda-i for defining characteristics for ineffective airway clearance. crackling and wheezing are lung sounds but they are not components of airway clearance, which refers more to removing secretions, cough, etc. diminished lung sounds would fit, but you don't have those in your scenario; on the contrary, they are described as "loud." fwiw, students often fall in love with the sound of a nursing diagnosis, even if it doesn't really quite fit, and then they try to cram their facts into it. i don't think this one fits.

    read the nanda-i 2012-2014 (you can get it with free 2-day shipping if you're a nursing student, i hear) on the details. but hey, it's your care plan. if you can justify it (and i'm not hearing that quite yet), you get to do it. as to what to do first, i gave you my opinion already.
    :d

    @ grownuprosie, yeah, it's wonkey, which is why i said this guy is gonna be in arrest soon, but hey. the purpose of it is to assess and plan c the conditions at hand. it would be too scary to ask a student to go further c this scenario, eh?
    sandanrnstudent and grownuprosie like this.
  12. 3
    Oh my! Is this the stuff they are teaching in nursing school now days? Uggg, glad I grew up with a more medical model. At what point do they teach, "OMG, this guy is in big trouble. I have done all I know to do, and he is circling the drain. He is not a DNR, I better get somebody who can do something else. Call the doctor? Call the supervisor? Call respiratory therapy (because he needs BiPap), give some morphine?" I'm a firm believer in prayer, but critical thinking goes way beyond figuring out what to call the problem as the patient dies.

    I am so glad I don't have to deal with this stuff. No wonder nursing school makes people crazy!
    Just my opinion, and not at all helpful to the OP. I'm still shaking my head in wonder!!

    The people who are designing these scenarios must be the same people on hospital regulatory commissions. None of them seem to be in touch with reality!
    FineAgain, psu_213, and grownuprosie like this.


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