Can you help me with my nursing diagnosis?

[starrys]

I need to do a care plan related to RESPIRATORY. The patient I had was a 69 yo female. Her diagnosis was sepsis, UTI, anemia, COPD, and lung cancer. She also has psychosis with paranoid personality trait, confused, and agitated. She was not on nasal cannula, just room air. She coughed occasionally, and sounded productive. She had a high fever which was not going down and they were trying to find the reason behind it. it could be the uti or sepsis. I had to help her eat her food because she wasn't eating. on the 2nd day, she was very lethargic and her dentures were very loose. i fed her once and she barely chewed her food so i stopped feeding her. I took off her dentures.

Her lung and heart sounds were clear, confirmed by the nurse.

I honestly do not know where to start because she has a lot of things going on. I think her psychosis is important, but how do I incorporate that into a respiratory diagnosis?

Do I do impaired gas exchange b/c of her lung cancer or tumor mass?

[tarheelsu]

So if you have to do respiratory you probably have ineffective airway clearance or impaired gas exchange. You need to have a care plan book. Look up the defining characteristics for these diagnoses and see what assessment data you have.

Airway could relate to obstruction (tumor, mucus, etc), it could relate to a weak cough. If the patient has been on prolonged bedrest, they probably are weak, that could lead to a weak cough. If you have mental status problems then they probably can't make a controlled effort to cough and clear their airway. Prolonged fever could lead to fluid deficit which can make secretions thicker and more difficult to clear.

Gas exchange can be related to the history of COPD - she probably gas less alveolar surface for gas exchange, immobility/ bedrest can lead to decreased lung expansion which would cause less air to come in the lungs for exchange, secretions pooling in the bases cause less surface for exchange.

So I would look at these two, see what supporting assessment data you have and go from there.