i'm sorry i couldn't reply to your post yesterday, but i have class on wednesday evenings myself and have trouble getting online late evenings.
no, your diagnosis is appropriate. i might change the wording of it to something like this: impaired spontaneous ventilation r/t respiratory muscle fatigue secondary to respiratory failure and respiratory insufficiency
. i wouldn't use respiratory insufficiency as my related tp factor in my nursing diagnostic statement because it is a medical diagnosis. it's usually ok with nursing instructors to list medical diagnoses after the words "secondary to" because that clearly sets them apart from the nursing diagnostic part of the statement.
goals and outcomes are usually based on the problems the patient has to begin with. since you haven't really assessed the patient fully yet, you need a care plan book or some other resource to help you with this. my copy of nursing diagnoses: definitions & classification 2005-2006 published by nanda international, on page 214, lists these as the defining characteristics (abnormal assessment data you normally find) of this particular nursing diagnosis:
assuming your patient might have one or more of those problems, your goals for her will revolve around those. first, of all if you look at that list you notice that pco2, po2 and sao2 are mentioned. the only way you are going to find those measurements is on arterial blood gas results. so, one of your goals right off the bat should be:
- increased metabolic rate
- increased pco2
- increased restlessness
- increased heart rate
- decreased tidal volume
- decreased po2
- decreased cooperation
- decreased sao2
- increased use of accessory muscles
also, with an et tube stuck in her throat she has a foreign body that her body is trying to fight off physiologically. she's most likely going to be having a lot of secretions and require a fair amount of suctioning. so:
- patient will have arterial blood gases within acceptable parameters
now, you are right. goals must be measurable, patient centered and specific. some instructors even want students to put timed deadlines on the goals as well. blood gases are measured by taking an arterial blood sample and testing the blood. i'll leave you to look up the normal blood gas parameters. but, you turn that statement into the following:
- patient will have a patent airway
that is a measurable and specific goal. as for the patent airway, you might write this:
- on ventilator settings of ________ the patient will have arterial blood gasses within a ph of ___, pco2 of ___, hco3 of ___, po2 of ___ and sao2 of ___.
i see that you are new to the forum. i would just like to point out that there are currently two threads with "stickys" on them that specifically have tips for care plan writing. sticky threads always appear at the very top of thread listings. here are links to these threads. when you have time you should read through some of the postings on them as there is a lot of good information there:
- after pulmonary toilet and suctioning every 4 hours the patient will have a patent airway
if you need more help with this, please ask. welcome to allnurses!