can someone help with my care plan??

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I want to know whether the diagnosis is correct or not.

Mr. Wong is 50 years old and has been diagnosed with lung cancer for a few months.

He is admitted with chest wall pain(He rates 6) and dyspnea. He has poor appetite and loss his weight

He sleeps poorly and cries at night

BP: 120/80 mmHg

P: 120/min

RR: 30/min

SaO2: 80%

Whening taking to the nurse, he is depressed and dyspnoeic

Nursing diagnosis:

1、activity intolerance

2、ineffective breathing patterns

3、imbalanced nutrition,less than body requirement

4、anxiety

5、insomnia

6、Ineffective airway clearance

7、acute pain

8、ineffective tissue perfusion

9、impairedgas exchange

Are these correct??

Are there any things else need to add??

Thank you!

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Specializes in Emergency Nursing.

Many of you diagnosis are related to other nursing diagnosis.

1.) Activity Intolerance (No) he's intolerant of activity because he can't breathe and is in pain

2.) Ineffective breathing pattern (maybe) but likely because he is in pain and has poor gas exchange

3.) Nutrition less than body requirements (Probably) but he's not eating because he is in pain and can't breathe

4.) Anxiety (No) he's anxious because he's in pain and can't breathe

5.) Insomnia (No) again because he's in pain and can't breathe

6.) Ineffective airway clearance (maybe) signs symptoms of airway clearance? wheezes? rhonchi?

7.) Acute Pain (yes)

8.) Ineffective tissue perfusion (maybe) you'd need to present more evidence to support this DX, nothing you presented above would support this dx.

9.) Impaired gas exchange (yes)

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Duplicate :confused:

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Many of you diagnosis are related to other nursing diagnosis.

1.) Activity Intolerance (No) he's intolerant of activity because he can't breathe and is in pain

2.) Ineffective breathing pattern (maybe) but likely because he is in pain and has poor gas exchange

3.) Nutrition less than body requirements (Probably) but he's not eating because he is in pain and can't breathe

4.) Anxiety (No) he's anxious because he's in pain and can't breathe

5.) Insomnia (No) again because he's in pain and can't breathe

6.) Ineffective airway clearance (maybe) signs symptoms of airway clearance? wheezes? rhonchi?

7.) Acute Pain (yes)

8.) Ineffective tissue perfusion (maybe) you'd need to present more evidence to support this DX, nothing you presented above would support this dx.

9.) Impaired gas exchange (yes)

I disagree. They still need to be addressed- just because they're related doesn't make them irrelevant in and of themselves :).

Activity intolerance d/t impaired gas exchange AEB SaO2 %80, altered vital signs

Ineffective breathing pattern d/t lung cancer AEB c/o dyspnea & O2 sats; RR 30

Nutrition less than body requirements d/t poor appetite AEB weight loss

Anxiety d/t (how it's phrased for changes in health status) AEB crying at night (BUT...this needs more back up info- i.e. pt c/o anxiety

Insomnia d/t (a lot of things- he's got cancer, dyspnea, anxiety, pain) AEB being awake on rounds

# 6- need more information on that one (agree)

# 7- yep... pain per pt complaints

# 8- O2 sats of 80%/ RR 30/pulse 120 sound pretty ineffective to me; body attempting to compensate for ineffective/inadequate O2 :)

# 9- yep (dyspnea when talking, O2 sats, RR-30, HR 120- all looking for more air...)

ADD- something re: diagnosis of cancer and psycho-social implications

ADD- spiritual component d/t psycho-social issues/major life change

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Specializes in LTC, Psych, Hospice.

I'd put pain & ineffective breathing toward the top. To me, those are more important than activity intolerance & insomnia.

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do you need specific or priority nursing diagnosis be clear

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do you need specific or priority nursing diagnosis be clear

First line in the original post = needs to know if they are correct or not :)

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I disagree. They still need to be addressed- just because they're related doesn't make them irrelevant in and of themselves :).

Activity intolerance d/t impaired gas exchange AEB SaO2 %80, altered vital signs

Ineffective breathing pattern d/t lung cancer AEB c/o dyspnea & O2 sats; RR 30

Nutrition less than body requirements d/t poor appetite AEB weight loss

Anxiety d/t (how it's phrased for changes in health status) AEB crying at night (BUT...this needs more back up info- i.e. pt c/o anxiety

Insomnia d/t (a lot of things- he's got cancer, dyspnea, anxiety, pain) AEB being awake on rounds

# 6- need more information on that one (agree)

# 7- yep... pain per pt complaints

# 8- O2 sats of 80%/ RR 30/pulse 120 sound pretty ineffective to me; body attempting to compensate for ineffective/inadequate O2 :)

# 9- yep (dyspnea when talking, O2 sats, RR-30, HR 120- all looking for more air...)

ADD- something re: diagnosis of cancer and psycho-social implications

ADD- spiritual component d/t psycho-social issues/major life change

I agree.

I'd put pain & ineffective breathing toward the top. To me, those are more important than activity intolerance & insomnia.

And I agree.

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Respiratory should be your focused assessment in this case. Your priority nursing Dx should be related to respiratory. The other dx u listed come second, third.Hope this helps.

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Specializes in Med-Surg/urology.

Just agreeing with everyone else. In school we learned that while writing our dianoses, prioritize. Remeber your abc's, and in this case all the respiratory diagnoses would be listed first.

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your diagnosis are okey but u need to address them in priority like air way clearance and brething pattern , pain then others come as specific

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I had always learned in n. school that if you did not have 3 pieces of evidence to support the nursing dx then you shouldn't use it in your care plan. With the info that you've given many of the listed dx shouldn't be used. Your breathing dxs (ineffective tissue perfusion, airway clearance, etc) are going to be your priorities and you should be searching through this patient's file/lab results, etc to find more evidence. When a pt has respirations of 30 and a medical dx of lung cancer the nutrition and anxiety nursing dx, although important, are a HUGE 2nd to the obvious problem.

PS. Acute pain is always always a priority.

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