Can someone help me with nursing diagnosis on this patient?

[starrys]

I need help with writing my care plan that has to do with respiratory.

My patient yesterday was a 69 year old female with sepsis. seconday problems was uti, anemia, lung cancer, and copd. She also has paranoid psychosis and is very confused and combative at times. when i listened to her lungs, there were no adventitious sounds. her bp was 148/86, temp normal, pulse 76, respirations 22, spo2 97%. i noticed her nasal cannula was off so she had labored breathing. i told the nurse and put the nasal cannula back on. her labored breathing calmed down. I'm stuck as to what i can do my nursing diagnosis. Is ineffective airway clearance r/t chronic obstructive pulmonary disease and lung cancer okay? or impaired gas exchanged r/t lung cancer or copd?

[carsonya]

Because we are nurses we can never write AEB a medical diagnosis (only doctors can) so instead you can write impaired airway clearance R/T excessive mucus secretion AEB patient unable to clear secretions, labored breathing, (did you measure the O2 sat without the NC) (or you could write the pt required NC at however many liters to keep O2 sat above 90%) and as many pt specific symptoms you can find

you can only use impaired gas exchange if you have the ABG results, because without them you cannot assess the gas exchange

as for interventions make them as specific as possible for your pt

example. 1. Assess the pt O2 sat Q 4 hrs during the shift ; i usually write 5 interventions 1 is always the assessment & 5 is some sort of pt teaching i did.

the Nursing Diagnosis Handbook really helps if you dont already have it, you look up whatever disease process your patient has and it lists related diagnoses to that disease. Hope that helps :)

[classicdame, MSN, EdD]

don't forget the psychosocial diagnoses either. She has more than physical needs that should be addressed.

[systoly]

Does she take the O2 off herself?

[nurseprnRN, BSN, RN]

i think either one is good. you could even use both, depending on what her illness really is, because it's perfectly possible for one person to have both simultaneously.

you can use a medical diagnosis as a "related to" (i have said before that "r/t" and "aeb" should be banned from nursing student-land in favor of "because s/he has" and "and i know this because i assessed this: ..." because that makes it so much clearer) it is perfectly acceptable to say, "impaired sensation because patient has diabetic neuropathy, and i know this because she reports a burning sensation in her feet, cannot feel her feet when she walks on the ground, and is unable to feel when her feet are injured."

remember that airway clearance is a mechanical thing-- is the airway well, clear? mucus, foreign body, tumor, bronchiectasis (look it up), clot, big pleural effusion, big ascites, neuromuscular disease with diaphragmatic weakness, high sci, severe malnutrition and weakness -- all of these are mechanical things that will decrease the patient's ability to move air in and out. lungs could be perfect, but the ventilation is bad.

impaired gas exchange happens at the alveolar level-- for some reason, gases aren't doing their capillary-bed-to-alveolus do-si-do well. this can be because the patient has thickened alveolar walls, burns, infection/inflammation, congestive heart failure with pulmonary edema, toxic gas injury so the gases have farter to go between the alveolus and the capillary, so it's less efficient; or also something like a big old pulmonary embolus that's preventing a lot of alveoli from seeing any blood flow, so they can't do their job or gas exchange even though they would like to.

[BBRANRN2013, ASN, RN]

We are NOT allowed to use medical diagnoses as our r/t. The above poster is correct!

[PsychNurseWannaBe, BSN, RN]

This is a student forum and most programs do not allow students to use medical diagnoses in their care plans unless it is a secondary to: What we do in the real world is a different animal.