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Discussion

Care plan question

I'm currently working on my second care plan for a case study before we start going to LTC facilities next week. This is my assessment info:

Objective:

1. T 97.7 oral, P 86, RR 21, O2 sat 98% on room air

2. no edema, less than 3 second capillary refill

3. Hx of HTN, diabetes, tobacco use, COPD

4. On bed rest with SOB on exertion, including turning

5. Audible wheezing on auscultation

6. Labored breathing,; rapid & deep respirations

7. Patient is tearful

8. Palliative care order for medical diagnosis of end-stage COPD

Subjective:

1. c/o SOB and non-productive cough

2. Voices a fear of dying

potential Diagnoses:

1. Activity Intolerance r/t immobility, bed rest, generalized weakness, and imbalance between oxygen supply/demand.

2. Death Anxiety r/t experiencing dying process, negative thoughts about death and dying, reported fear of dying, and palliative care order.

We are supposed to have a total of 3 diagnoses. I have considered impaired skin integrity, but I don't feel like I have enough information to support that diagnosis because although he has difficulty turning and is on bed rest, he does not have impaired circulation, edema, incontinence, etc.

If anyone could give me some guidance (I'm not asking you to do my work for me; I know I need to learn this stuff) I would appreciate it!

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    • Featured Replies

    I would personally go with Ineffective airway clearance r/t c/o non-productive cough. I hope this helps. Keep in mind I am only in my first semester of the program and we are now covering care plans. Good luck!

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    I agree with the above...is Activty intolerance going to kill her before her Impaired Gas Exchange r/t decreased surface air of alveoli 2° COPD or Emphysema more specifically AEB.....

    Food for thought...

    ABS's first

    Then Maslows, etc....

    What was this pts blood pressure?

    What was this Pts prognosis,like how long?.and was she palliative on comfort care or just palliative consulted?

    death anxiety is ok but what about her nutrional or fluid balance? What would constant increased WOB and SOB cause the body to do?

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    • Author

    He is end-stage COPD which is why the palliative care order was ordered. I'm not sure if it was comfort care, but the case study says that he is "tearful" and "voices a fear of dying" which is why I chose death anxiety. His b/p and pulse are normal, respirations are rapid and he has wheezing on auscultation. I'm thinking that SOB could affect his oxygen levels? But his O2 saturation is 98% on room air.

    Ineffective Airway Clearance definitely makes sense, though!

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    He is end-stage COPD which is why the palliative care order was ordered. I'm not sure if it was comfort care, but the case study says that he is "tearful" and "voices a fear of dying" which is why I chose death anxiety. His b/p and pulse are normal, respirations are rapid and he has wheezing on auscultation. I'm thinking that SOB could affect his oxygen levels? But his O2 saturation is 98% on room air.

    Ineffective Airway Clearance definitely makes sense, though!

    Ok clearly I know why palliative was ordered, but that doesnt mean the patient is going to die in a day or week, people can live a while and be palliative, look up the definition, it does not mean immediately dying. Theres a difference. Why do you think that it is airway clearance? Usually that ND is used with secretions. Oxygen levels and the patho of COPD as mentioned in my previous post causes SOB not other way around.

    Ineffective breathing pattern would work too.

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    • Author

    I was just answering your question... I wasn't trying to insult your intelligence (sorry if it came across that way)!

    According to my care plan book, Ineffective airway clearance can manifest in patients with COPD. Since the pt is unable to create a productive cough and has wheezes on auscultation (indicating that there is an airway obstruction) I am assuming that his inability to clear his airway is the most significant problem.

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    Keep in mind that this resident will have anxiety related to the sob and not just the death process. Try breathing under your covers for two minutes and you might be able to empathize with this anxiety from being so sob. I had a resident like this during my first nursing job fresh out of nursing school. It was awful watching her...she was literally suffocating to death bc of her end stage copd. She seemed almost eager to pass :(

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    And I'm curious...if this pt is on room air and is so sob he can't get out of bed and is on palliative care for copd why is he not on oxygen?

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    • Author

    @lvnlrn honestly I'm not sure. I figured his O2 saturation would be well below 98% and/or he would be on oxygen but alas that was not the case.

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    • Experts

    1. T 97.7 oral, P 86, RR 21, O2 sat 98% on room air

    2. no edema, less than 3 second capillary refill

    3. Hx of HTN, diabetes, tobacco use, COPD

    4. On bed rest with SOB on exertion, including turning

    5. Audible wheezing on auscultation

    6. Labored breathing,; rapid & deep respirations

    7. Patient is tearful

    8. Palliative care order for medical diagnosis of end-stage COPD

    Subjective:

    1. c/o SOB and non-productive cough

    2. Voices a fear of dying!

    My thoughts are....

    Is his activity intolerance due to his bedrest or is his bedrest ordered/necessary because of his activity intolerance.

    With ineffective airway clearance you do have proof with the wheezing that was auscultated.

    You also have impaired gas exchange even with a sufficient O2 sat.

    Look at your definitions......

    Impaired gas exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

    defining characteristics: Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances (your patient has COPD and wheezes nasal flaring is SOB)

    related to: Ventilation-perfusion imbalance; alveolar-capillary membrane changes (COPD)

    ineffective airway clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

    defining characteristics: Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed

    related to:

    Environmental Secondhand smoke; smoke inhalation; smoking

    Obstructed Airway Airway spasm; excessive mucus; exudate in the alveoli; foreign body in airway; presence of artificial airway; retained secretions; secretions in the bronchi

    Physiological Allergic airways; asthma; COPD; hyperplasia of the bronchial walls; infection; neuromuscular dysfunction

    How about Fear....just plain old fear.

    Fear: Response to perceived threat that is consciously recognized as a danger

    Report of alarm; apprehension; being scared; increased tension; decreased self-assurance; dread; excitement; jitteriness; panic; terror

    Cognitive: Diminished productivity; learning ability; problem-solving ability; identifies object of fear; stimulus believed to be a threat

    Behavior: Attack or avoidance behaviors; impulsiveness; increased alertness; narrowed focus on the source of fear

    Physiological Anorexia: diarrhea; dry mouth; dyspnea; fatigue; increased perspiration, pulse, respiratory rate, systolic blood pressure; muscle tightness; nausea; pallor; pupil dilation; vomiting

    Related Factors (r/t): Innate origin (e.g., sudden noise, height, pain, loss of physical support); innate releasers (neurotransmitters); language barrier; learned response (e.g., conditioning, modeling from or identification with others); phobic stimulus; sensory impairment; separation from support system in potentially stressful situation (e.g., hospitalization, hospital procedures); unfamiliarity with environmental experience(s)

    Ackley: Nursing Diagnosis Handbook, 10th Edition
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