I'm second semester nursing student and am getting my first 'real' care plan ready to turn in Monday.
I had a really good pt. to do my care plan on, but I'm just really lost when it comes to getting my nursing d/x together. We have to have 2 priority diagnoses, with 3 intervention each.
My pt. is late 70's who came in with an acute gout attack, L arm and leg swelling and extreme pain. She has CAD, hypertension, pneumonia and an asymptomatic UTI right now. she has h/x of hyperlipidemia as well.
She had an O2 stat around 95% on RA, BP is a little high, but her other VS were WNL.
She also has an ileostomy bag, but her skin and it is in great condition.
Her chest x-ray was for "follow up pneumonia" and revealed "adjacent atelectasis, cardiac silhouette enlarged, tortuous aorta with calcifications, background of interstitial disease". She also has a h/x of Rheumatoid Aarthritis which affects her mobility. Her H&H were both decreased, WBC increased, RBC decreased, BUN/cret increased. Her elec were all within normal limits.
She had diminished lung sounds in bases and some edema in LUE and LLE.
I guess where I need help is:
1.My nursing d/x. I have 2 that I've come up with and are listed by priority:
Impaired Tissue Perfusion
Impaired physical mobility
2. I am not sure how I want to/what diagnosis to choose to address the pneumonia and CAD. I was thinking impaired tissue perfusion BECAUSE of the atelectasis, and background of interstitial disease found on the x-ray; and because with the CAD-her perfusion capabilities are diminished, right?
Am I on the right track?
I put the impaired physical mobility as my second one because I feel like all of her health issues/conditions affect her mobility and because her mobility is something that I can set measureable outcomes for and have multiple interventions.
BUt again, I really have no idea what im doing!
3. Im trying to figure out WHY her lab values are they way they are. Esp the BUN/Cret and the H&H. Im just very curious and cant seem to connect the pieces.
I would reallllllllly appreciate some help here, im feeling like im not seeing something or addressing something I need to address. Thanks!
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Ineffective Breathing Pattern
R/T Alveolar-capillary membrane changes, secondary to medical d/x pneumonia; shortness of breath, difficulty breathing and respiratory muscle fatigue.
I feel like this one does apply to her better than the other ones.
Does she have shortness of breath? Does she complain of fatigue? I am not saying she doesn't have this diagnosis I'm saying your reason why she might have this is wrong.
What is atelectasis.....http://www.nhlbi.nih.gov/health/health-topics/topics/atl/
YOU are still NOT looking at the definition....this diagnosis has nothing to do with Alveolar-capillary membrane changes that would be impaired gas exchange.
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
So Im thinking that my two d/x are:
1.
Ineffective Breathing Pattern
R/T Alveolar-capillary membrane changes, secondary to medical d/x pneumonia; shortness of breath, difficulty breathing and respiratory muscle fatigue.
AEB: SUB: Pt. stated, “My chest [sternum] hurts” and c/o SOB when attempting to lie flat. Pt’s also stated, that when attempting to ambulate to the BR, she gets extremely SOB and fatigued, so she has been using the w/c instead of her r/w.
OBJ: Diminished lung sounds bilaterally in the bases. Pt. exhibited orthopnea. Chest x-ray done 09/29 for “follow up pneumonia” revealed “adjacent atelectasis, cardiac silhouette enlarged, tortuous aorta with calcifications, and background of interstitial disease”.
2.
Impaired Physical Mobility
R/T Musculoskeletal impairment with LUE/LLE edema and severe pain; secondary to medical diagnosis of GOUT. Joint inflammation and ROM impairment; secondary to medical diagnosis of RA. Respiratory impairment effecting pt’s ability to perform tasks and ADL’s without becoming fatigued and SOB, secondary to medical diagnosis of pneumonia.
AEB: SUB: Pt. c/o “severe pain” in LUE and LLE which is “stopping me from moving and walking like I was before this [recent gout attack]”. Pt. also says the swelling in her LUE and LLE r/t the GOUT attack is something else that is preventing her from doing her everyday ADL’s “like going to the bathroom, bathing and getting dressed; along with using her walker”. Pt. c/o of inflammation and chronic pain in her joints (“mostly hands, knees and back”) which limits what she has been able to physically do. Pt. c/o of getting breathless faster since she was diagnosed with pneumonia which has resulted in her not being able to walk as far, stay up as long or complete some daily tasks like she was doing before.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
So Im thinking that my two d/x are:
1.
Ineffective Breathing Pattern
R/T Alveolar-capillary membrane changes, secondary to medical d/x pneumonia; shortness of breath, difficulty breathing and respiratory muscle fatigue.
AEB: SUB: Pt. stated, “My chest [sternum] hurts” and c/o SOB when attempting to lie flat. Pt’s also stated, that when attempting to ambulate to the BR, she gets extremely SOB and fatigued, so she has been using the w/c instead of her r/w.
OBJ: Diminished lung sounds bilaterally in the bases. Pt. exhibited orthopnea. Chest x-ray done 09/29 for “follow up pneumonia” revealed “adjacent atelectasis, cardiac silhouette enlarged, tortuous aorta with calcifications, and background of interstitial disease”.
2.
Impaired Physical Mobility
R/T Musculoskeletal impairment with LUE/LLE edema and severe pain; secondary to medical diagnosis of GOUT. Joint inflammation and ROM impairment; secondary to medical diagnosis of RA. Respiratory impairment effecting pt’s ability to perform tasks and ADL’s without becoming fatigued and SOB, secondary to medical diagnosis of pneumonia.
AEB: SUB: Pt. c/o “severe pain” in LUE and LLE which is “stopping me from moving and walking like I was before this [recent gout attack]”. Pt. also says the swelling in her LUE and LLE r/t the GOUT attack is something else that is preventing her from doing her everyday ADL’s “like going to the bathroom, bathing and getting dressed; along with using her walker”. Pt. c/o of inflammation and chronic pain in her joints (“mostly hands, knees and back”) which limits what she has been able to physically do. Pt. c/o of getting breathless faster since she was diagnosed with pneumonia which has resulted in her not being able to walk as far, stay up as long or complete some daily tasks like she was doing before.
and im still working on the OBJ data for that one
Your first diagnosis can't be Alveolar-capillary membrane changes. They may have ineffective breathing pattern but from the limited lung capacity from the atelectasis.
Breathing PATTERN has nothing to do with GAS exchange.
What about the one that jumps off the page that is limiting your patient breathing and activity...PAIN...it is the fifth vital sign
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
Yes! because she is in such pain-that would absolutely affect her breathing.
The alveolar membrane part was still typed in from when I was working on the impaired gas exchange d/x. I have changed my r/t now to: Respiratory muscle fatigue, secondary to medical d/x pneumonia; limited lung capacity from atelectasis; shortness of breath and difficulty
breathing from pt’s pain level.
im not sure how I should exactly word the pain portion of that.
does the second one look okay so far? Im working on the objective data now.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Yes! because she is in such pain-that would absolutely affect her breathing.
The alveolar membrane part was still typed in from when I was working on the impaired gas exchange d/x. I have changed my r/t now to: Respiratory muscle fatigue, secondary to medical d/x pneumonia; limited lung capacity from atelectasis; shortness of breath and difficulty
breathing from pt’s pain level.
im not sure how I should exactly word the pain portion of that.
does the second one look okay so far? Im working on the objective data now.
NO...acute PAIN for a diagnosis?
Put you nursing diagnosis and information into this statement.
A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__." (GrnTea)
Related to" means "caused by," not something else.
...does it make sense? If not then you need to re-word it.
Impaired breathing pattern R/T Alterations in depth of breathing decreased vital capacity, dyspnea AEB abnormal CXR(atelectesis) patient c/o SOB/fatigue and pain...now what other assessment data do you have other than her complaints...what was her resp rate? Did she use pursed lip breathing?
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
Oh acute pain for a diagnosis!!? Would that be a better one than the impaired mobility? I feel like if her pain was managed then the mobility would be better right?
and yes there was more assessment data that I saw that supported it: Diminished lung sounds bilaterally in the bases. Pt. exhibited orthopnea, use of accessory muscles and dyspnea. Chest x-ray done 09/29 for “follow up pneumonia” revealed “adjacent atelectasis, cardiac silhouette enlarged, tortuous aorta with calcifications, and background of interstitial disease”.Pt’s depth of breathing is shallow. Felt light vibrations over pt’s chest while she was speaking (fremitus).
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Sorry had to make dinner.
Yesssssss!!! There you go! do you see how you got there? Pain is a priority and it is affecting may other of her problems. It is ABCd Airway, Breathing, Circulation, disability. I think you have to take care of her pain to help her mobility
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Look at this there is one word that stands out to me....
1.
Ineffective Breathing Pattern
R/T Alveolar-capillary membrane changes, secondary to medical d/x pneumonia; shortness of breath, difficulty breathing and respiratory muscle fatigue.
AEB: SUB: Pt. stated, "My chest [sternum] hurts" and c/o SOB when attempting to lie flat. Pt's also stated, that when attempting to ambulate to the BR, she gets extremely SOB and fatigued, so she has been using the w/c instead of her r/w.
OBJ: Diminished lung sounds bilaterally in the bases. Pt. exhibited orthopnea. Chest x-ray done 09/29 for "follow up pneumonia" revealed "adjacent atelectasis, cardiac silhouette enlarged, tortuous aorta with calcifications, and background of interstitial disease".
2.
Impaired Physical Mobility
R/T Musculoskeletal impairment with LUE/LLE edema and severe pain; secondary to medical diagnosis of GOUT. Joint inflammation and ROM impairment; secondary to medical diagnosis of RA. Respiratory impairment effecting pt's ability to perform tasks and ADL's without becoming fatigued and SOB, secondary to medical diagnosis of pneumonia.
AEB: SUB: Pt. c/o "severe pain" in LUE and LLE which is "stopping me from moving and walking like I was before this [recent gout attack]". Pt. also says the swelling in her LUE and LLE r/t the GOUT attack is something else that is preventing her from doing her everyday ADL's "like going to the bathroom, bathing and getting dressed; along with using her walker". Pt. c/o of inflammation and chronic pain in her joints ("mostly hands, knees and back") which limits what she has been able to physically do. Pt. c/o of getting breathless faster since she was diagnosed with pneumonia which has resulted in her not being able to walk as far, stay up as long or complete some daily tasks like she was doing before.
Seems to me the pain is pretty significant to her. Remember it is about the patient.
NewNurse91D
109 Posts
Ineffective Breathing Pattern
R/T Alveolar-capillary membrane changes, secondary to medical d/x pneumonia; shortness of breath, difficulty breathing and respiratory muscle fatigue.
I feel like this one does apply to her better than the other ones.