I am a first semester nursing student, so imagine me as a child trying to learn Nursing Diagnosis and Care plans :) I could use some assistance!
For a class assignment, we were split into pairs and had to listen to ask about health history, do a physical examination including inspection, palpation, percussion, auscultation, and then find subjective and objective information about the patient. Since it was a classmate, we had to come up with her "chief complaint." I am having difficulty creating a wellness diagnosis and the plan to go along with it.
Chief complaint: S.O.B. and cough with activity
Health History: Smoker on average 10 cigarettes/week, Currently has a productive cough with green phlegm.
Objective findings were all "normal" for this hypothetical patient. Thoracic cage symmetrical, Respiratory rate 15 breaths/minute and even, skin pink and intact, alert and oriented x3... Clear in all lung fields, no adventitious sounds, hollow resonance, no lumps, and trachea is midline to the body...
If I were trying to write a WELLNESS diagnosis, can I do this:
"Readiness for enhanced self-Health management R/T Patient expresses desire to improve breathing capacity"
Then the patient outcome would be "patient will explain 3 ways to improve breathing capacity before discharge" ..?
I also thought "Risk for ineffective airway clearance r/t discolored sputum production." Would this work for a diagnosis if I were aiming for Risk? (we are supposed to come up with a Wellness one so I decided to avoid this for the most part...)
My biggest confusion then, comes from the Nursing Intervention and Rationales. My understanding at first was that we are supposed to create ways to show a patient the resources they need, or how to use certain tools. Example-- Incentive spirometer. The reason I am confused is that there is no "Incentive Spirometer" option in my NANDA textbook. Does this make sense, and can somebody help walk me through this so I can understand?? I see an option in the textbook "help the client maintain existing support and seek additional support as needed" and that is under the category Self-Health Management, but I just seem to be missing a step here somewhere! Thanks for the help! :)
