Diagnoses case scenario...

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Mr. John Anthony is a 61 year old man with a history of chronic bronchitis. He has an 80 pack a year smoking history (two packs a day for 40 years). He is being seen in the clinic for complaints of copious thick secretions and the feeling that he is choking on his own sputum. He states that "except for this respiratory problem, my health is good."

Mr. Anthony reports paroxysmal coughing episodes but feels as if he canot clear his throat, even after coughing. On examination his respiratory rate is 28 bpm and respiration is unlabored; he has bilateral wheezes on auscultation, frequently attempts to clear his thraot, and brings up thick yellow mucus with coughing. Mr. Anthony reports that he frequently feels tired in the afternoons and takes a nap after lunch every day. He is independent in all activities of daily living and plays golf three times per week. He eats a well balanced low fat diet. He reports a fluid intake of five to six cups of tea or coffee per day and one mixed drink in the evening.

Clustering:

1)

copius thick secretions

paroxysmal coughing

History - chronic bronchitis

History - 2 pack a day, 40 years

R.R. is 28

respiration unlabored

bilateral wheeze - auscultation

frequent attempts to clear throat

thick, yellow mucus with coughing

2)

frequently tired in afternoon

take nap after lunch

3)

independent in activity

gold three times a week

4)

well-balanced diet

This is the clustering i have come up with so far... I'm not exactly sure where to place the feeling of choking and feeling of inability to clear throat, and also the fluid intake..

I've heard that you should drink clear liquids for mucus problems, so i was thinking of placing the fluid intake under the 1st cluster.. and with the feelings, i'm totally spazzed on where to put those :(..

Any help would be greatly appreciated :D

Edit:: should the 2nd cluster remain its own or should i place that under the 1st? i'm thinking the mucus problem is affecting his sleeping pattern, thus causing feeling of tiredness in afternoon and the nap..

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mr. john anthony is a 61 year old man with a history of chronic bronchitis. he has an 80 pack a year smoking history (two packs a day for 40 years). he is being seen in the clinic for complaints of copious thick secretions and the feeling that he is choking on his own sputum. he states that "except for this respiratory problem, my health is good."

mr. anthony reports paroxysmal coughing episodes but feels as if he canot clear his throat, even after coughing. on examination his respiratory rate is 28 bpm and respiration is unlabored; he has bilateral wheezes on auscultation, frequently attempts to clear his thraot, and brings up thick yellow mucus with coughing. mr. anthony reports that he frequently feels tired in the afternoons and takes a nap after lunch every day. he is independent in all activities of daily living and plays golf three times per week. he eats a well balanced low fat diet. he reports a fluid intake of five to six cups of tea or coffee per day and one mixed drink in the evening.

clustering:

1)

copius thick secretions

paroxysmal coughing

history - chronic bronchitis

history - 2 pack a day, 40 years

r.r. is 28

respiration unlabored

bilateral wheeze - auscultation

frequent attempts to clear throat

thick, yellow mucus with coughing

2)

frequently tired in afternoon

take nap after lunch

inability to clear secretions

frequent cough

3)

independent in activity

gold three times a week

4)

well-balanced diet

amount of fluid intake during the day

this is the clustering i have come up with so far... i'm not exactly sure where to place the feeling of choking and feeling of inability to clear throat, and also the fluid intake..

i've heard that you should drink clear liquids for mucus problems, so i was thinking of placing the fluid intake under the 1st cluster.. and with the feelings, i'm totally spazzed on where to put those :(..

any help would be greatly appreciated :D

edit:: should the 2nd cluster remain its own or should i place that under the 1st? i'm thinking the mucus problem is affecting his sleeping pattern, thus causing feeling of tiredness in afternoon and the nap..

i would put them here...the first 2 things contribute to the fatigue and the fluid is intake, like the diet.

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The fluid intake one makes sense.. But with the coughing and inability to clear throat, those are what the client is feeling..

Would those still go under the disturbed sleep pattern?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Clustering involves grouping similar symptoms. You've mixed in a lot of information that doesn't qualify as symptoms. Symptoms are needed as evidence to support nursing diagnoses. The only symptoms that I come up with after reading the scenario that are going to yield any nursing problems are:

  • complaints of copious thick secretions
  • feeling that he is choking on his own sputum
  • paroxysmal coughing episodes
  • feels as if he cannot clear his throat, even after coughing
  • respiratory rate is 28 bpm
  • bilateral wheezes
  • frequently attempts to clear his throat
  • thick yellow mucus with coughing
  • frequently feels tired in the afternoons and takes a nap after lunch every day

The underlying causes (etiology) for these may or may not be found in this information:

  • history of chronic bronchitis
  • 80 pack a year smoking history

The next step is to match the symptoms with defining characteristics listed with nursing diagnoses.

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Thank you very much, greatly appreciate your help and direction >

hmm.. the fluid intake wouldn't matter at all for the mucus?

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Specializes in med/surg, telemetry, IV therapy, mgmt.
thank you very much, greatly appreciate your help and direction >

hmm.. the fluid intake wouldn't matter at all for the mucus?

is that your problem determination? what are the symptoms that support it? i saw no symptoms of deficient fluid volume. check the defining characteristics listed under this diagnosis and see what is listed there. you have to have abnormal data to support a nursing problem.

all i saw were respiratory symptoms and perhaps one symptom to support fatigue.

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