diagnosis question....

[sleepy1010]

Hi everyone, I am working on a careplan for my nursing class. The careplan has to have a respiratory diagnosis. My pt was 1 day post op from a L hip replacement. I am thinking of using "risk for ineffective gas exchange related to decreased lung expansion secondary to recent anasthesia" ...but I think that i am wording it incorrectly. Does anyone one have any suggestions? Thanks a lot!!

[waitingforthedream]

Gosh, you have to have a respiratory?? How about if client does not have this issue?? Anywho: How about something to do with breathing issues d/t decreased ambulation?? I don't understand how you can just assume she will have a respiratory issue, is their any subjective/objective info you can throw out to us so we can help you more???? You need data to support any NANDA Dx.

[cardiacRN2006, ADN, RN]

I wouldn't say it had to do with anesthesia anymore. If she had decreased lung expansion it's because of decreased ambulation (hard to move) and is probably lying in bed all day due to pain.

She's at a higher risk for PE than anything. In fact, when you said "L hip" I said, "PE" in my head.

Needs: PT, SCDs on her good leg, frequent ambulation, prophylactic anticoagulation such as hep TID or lovenox, and just plain old coughing and deep breathing.

Medicate her 30 mins prior to ambulation and/or PT.

[sleepy1010]

The professor said because all the patients she gave us are post op that they should have at least a "risk for" dx related to the recent surgery. The pts labs were all normal, ABG's normal, vitals normal ect. he ambulated the first day post op and was actually released that day towards the end of my shift. I can think of plenty of interventions for a risk 4 ineffective breating pattern dx i just cant seem to get a good "r/t". Thank you very much 4 ur suggestions:)

[cardiacRN2006, ADN, RN]

Like I said, she's at a very high risk for PE.

[waitingforthedream]

How about ineffective coughing???

[sleepy1010]

Thank you cardiacRN! that makes much more sense:) Does "Risk for Pumonary Embolism related to postoperative state" sound better?

[LoveTheNICU]

The problem with the "risk for pulmonary embolism" diagnosis is that it is not actually a nursing diagnosis. But you are on the right track. What nursing diagnosis would a pulmonary embolism cause?

[P_RN, ADN, RN]

I always "liked" potential for injury related to decreased respiratory expansion as evidenced by verbalization of pain on movement, shallow resps.....la di da. And the solution is already mentioned above. Move 'em, move 'em, move 'em.

[Daytonite, BSN, RN]

the patient was intubated during surgery and the throat and trachea are usually irritated after. many patients have sore throats from the et tubes. the reason patients are encouraged to deep breathe and cough is because their lungs are underinflated when they are anesthetized. in about 3 days they are going to start moving out huge lumps of thick sputum that accumulated in their lungs during the surgery if the deep breathing and coughing is done faithfully. the diagnosis you are looking for is risk for ineffective breathing pattern r/t the effects of anesthesia.

interventions for this nursing diagnosis is limited to:

• strategies to prevent the problem from happening in the first place
  
• monitoring for the specific signs and symptoms of this problem
  
• reporting any symptoms that do occur to the doctor or other concerned professional