Care Plan Help!

[patriciaperez]

I had a client diagnosed with pneumonia during my first med-surg rotation last week. I am currently working on my care plan. As one of my diagnoses I listed impaired gas exchange. The only thing I am having difficulty understanding is breath sounds. During my physical examination all anterior and posterior breath sounds auscultated sounded clear to me. Is this normal? I'm scared to ask my professor! Help any one?

[nurseprnRN, BSN, RN]

What makes you think he has impaired gas exchange? The definition of impaired gas exchange is ...? The defining characteristics for impaired gas exchange are .... ? If he does not have at least one of those defining characteristics, you cannot make that nursing diagnosis. It's like saying, "This animal doesn't have gills or scales or lay eggs to be fertilized externally, but it lives in the water, so I'm gonna diagnose it as being a fish." You will then misdiagnose ... the dolphin. :)

Breath sounds are not listed anywhere in the data to diagnose impaired gas exchange.

There's a pretty good thread going on here on nursing diagnosis which will help you if you read it all the way to the end. Here's the link:

https://allnurses.com/nursing-student-assistance/please-help-dx-815250.html