Care Plan help needed!

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.

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.

What NANDA resource do you have?

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

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.

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.

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?

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

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.