diagnosis related to lung cancer or respiratory

[starrys]

I need to do a care plan related to RESPIRATORY. The patient I had was a 69 yo female. Her diagnosis was sepsis, UTI, anemia, COPD, and lung cancer. She also has psychosis with paranoid personality trait, confused, and agitated. She was not on nasal cannula, just room air. She coughed occasionally, and sounded productive. She had a high fever which was not going down and they were trying to find the reason behind it. it could be the uti or sepsis. I had to help her eat her food because she wasn't eating. on the 2nd day, she was very lethargic and her dentures were very loose. i fed her once and she barely chewed her food so i stopped feeding her. I took off her dentures.

Her lung and heart sounds were clear, confirmed by the nurse.

I honestly do not know where to start because she has a lot of things going on. I think her psychosis is important, but how do I incorporate that into a respiratory diagnosis?

Do I do impaired gas exchange b/c of her lung cancer or tumor mass?

[nurseprnRN, BSN, RN]

didn't you post this somewhere else recently? you got a number of helpful answers to point you in the right direction. what did you do c them?

nursing diagnosis is derived from your nursing assessment, not from a list of medical diagnoses, and since we haven't assessed anything about her respiratory status and you haven't told us anything you know about it, we can't help you write your plan for nursing care. what did you assess? what specific questions do you have about what you found?

does she have signs of difficulty with airway clearance? with gas exchange? what would those be? (hint: pull out your nursing diagnosis book and look through the respiratory-related nursing diagnoses and see if you see defining characteristics there that match what you saw in your patient.)

[Cupcake89121]

Ditto what GrnTea said. If you're going to do a respiratory care plan, you need more nursing assessments that support whatever diagnosis you come up with. You mentioned some physical assessment, but what about other types? By that I mean vitals, labs, diagnostics, medications, IVs, wounds, I & O, diet, medical history, patient's chief complaint(s) etc. What is her pulse ox? I know that you auscultated her lungs, but did you observe the way the patient breathes? Purse-lipped, use of accessory muscles, etc. ?

The medical diagnosis definitely helps identify potential nursing diagnoses. I almost always use medical dx to look up potential nursing dx in my care plan book by Ackley. Ultimately though, it will be your assessments, observations, and conclusions that back up the nursing diagnosis.

Based on what you told us it sounds like Impaired gas exchange is a good nursing dx for this patient, but you have to know why (r/t) gas exchange is impaired and then prove it by showing how you know (aeb) gas exchange is impaired (aka EVIDENCE). I find it helpful to briefly review the A&P and patho. Gather all of your data, pick out what is abnormal, and then match it to the manifestations of the disease process.

You also mentioned psychosis and how you would incorporate that into a respiratory care plan -- I would ask myself: how does the patient's mental status relate to her respiratory problems? Lethargy, confusion, agitation...these are all are good indicators that patient isn't getting enough O2 = evidence of impaired gas exchange.

Sorry for all the rambling thoughts. This is just how I would approach this patient and care plan. I'm only a soon-to-be 3rd semester nursing student, so I hope I was able to help at least a little! :)

[NCRNMDM, ASN, RN]

I know I'm really late with this reply, but maybe some of what I say will help you in the future. In this situation, the psychosis isn't really all that important (unless the patient is currently suicidal, and a direct threat to herself). If the patient is simply a paranoid patient with a preexisting diagnosis of psychosis, then you don't need to consider it as a priority nursing issue for this patient (it will be an issue eventually, but there are more important areas to be concerned with at the moment). You don't give me much information to work with as far as the patient assessment goes. Some questions I would like to ask are: how are the vital signs? Is the patient tachycardic, hypotensive, etc? How has the urine output been lately? How high is the fever, and how long has it been high? What is the oxygen saturation, and does the patient need to be placed on some kind of oxygen therapy modality, or is she okay on room air? Do you think the confusion is due to her psychosis, or could there be another culprit for this issue? (Think sepsis, infection, fever, possible shock, low oxygen saturation, ineffective breathing pattern, etc). If the patient isn't eating, and probably isn't drinking, adequately what do her electrolytes and blood glucose readings look like? Has she had an ABG, and if so, what did it tell you about her acid-base balance?

Impaired gas exchange is an okay diagnosis, but what evidence do you have to back that up? Did you note a low oxygen saturation despite oxygen therapy on assessment? Did you note tachypnea, shortness of breath, excessive work of breathing, etc on assessment? You can't just give someone a diagnosis without evidence to back that diagnosis up. And you can't find the necessary evidence to make a proper nursing diagnosis without doing a thorough assessment. COPD can lead to impaired gas exchange, among other diagnoses, but you have to have evidence of that before you can make the diagnosis.

There are other respiratory diagnoses that can be made, but you must have evidence to support them. In addition to respiratory diagnoses, I would worry about a lot of other things. Risk for shock r/t hypotension and decreased CO secondary to sepsis, risk for falls r/t diminished mental status occurring with low oxygen saturation, imbalanced nutrition less than body requirements r/t lack of interest in food secondary to lethargy, impaired gas exchange r/t lung changes secondary to COPD, etc. This patient had a lot going on, and there are numerous issues that you could address.