diagnosis

Editorial Team / Admin · Mar 27, 2017

Please tell us your thoughts first. We are happy to help and clarify, but you need to show us what you've done first so that we can see what parts you're struggling with.

Trauma Columnist · Mar 27, 2017

Moved to nursing student assistance forum

meonemine · Mar 28, 2017

would this be in NANDA

Esme12, ASN, BSN, RN · Mar 28, 2017

would this be in NANDA

You would be taking your nursing diagnosis from NANDA but I cannot help you without more information.

So....you have already received my nursing diagnosis speech on a previous post. Like I said before....your nursing diagnosis comes from the assessment of your patient. You are falling into the same trap that traps other students...you are choosing a diagnosis and then you try to fit the patient into that diagnosis.

You chose ineffective airway clearance. NANDA defines this as: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. So, is your patient having trouble clearing their airway?

Defining characteristics (evidence/proof that this applies to your patient): Absent cough; adventitious breath sounds; alteration in respiratory pattern; alteration in respiratory rate; cyanosis; difficulty verbalizing; diminished breath sounds; dyspnea; excessive sputum; ineffective cough; orthopnea; restlessness; wide-eyed look. Does your patient exhibit AT LEAST 2 of these characteristics observed by you and revealed by your assessment?

Related to (the reasons WHY your patient would have this nursing diagnosis):

Environmental: Exposure to smoke; second-hand smoke; smoking

Obstructed Airway: Airway spasm; chronic obstructive pulmonary disease; exudate in the alveoli; excessive mucus; foreign body in airway; hyperplasia of bronchial walls; presence of artificial airway; retained secretions

Physiological: Allergic airways; asthma; infection; neuromuscular impairment

Does your patient fit anything in this category?

Nursing diagnosis is the recipe card that you, and others, will use to care for the patient based on what symptoms they have or that is revealed in your assessment of the patient.

So, Tell me about your assessment of your patient.....

meonemine · Mar 28, 2017

yes the patient has to wear oxygen all day I observed the patient acurity level the patient can't stand long in the shower without have dyspnea the patient smoked for 55 years & has asthma & coughs up sputum which has blood in it

Esme12, ASN, BSN, RN · Mar 28, 2017

yes the patient has to wear oxygen all day I observed the patient acuity level the patient can't stand long in the shower without have dyspnea the patient smoked for 55 years & has asthma & coughs up sputum which has blood in it

Ok...but what was your assessment? What did the lungs sound like? What was the O2 Sat? Did the patient have difficulty coughing up sputum? Did the sputum obstruct his airway? Did he have any edema? What were the patients vital signs?

A nursing diagnosis statement states the nursing diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

So your patient has ineffective airway clearance Related to (the reasons WHY your patient would have this nursing diagnosis):

Environmental: Exposure to smoke; second-hand smoke; smoking

Obstructed Airway: Airway spasm; chronic obstructive pulmonary disease; exudate in the alveoli; excessive mucus; foreign body in airway; hyperplasia of bronchial walls; presence of artificial airway; retained secretions

Physiological: Allergic airways; asthma; infection; neuromuscular impairment

If you look at your selected diagnosis ineffective airway clearance do you see any reference to cigarette smoking in your defining characteristics? The answer would be no.

As above.....It states the Defining characteristics of ineffective airway clearance (evidence/proof that this applies to your patient) as.... Absent cough; adventitious breath sounds; alteration in respiratory pattern; alteration in respiratory rate; cyanosis; difficulty verbalizing; diminished breath sounds; dyspnea; excessive sputum; ineffective cough; orthopnea; restlessness; wide-eyed look.

Now...which ones apply to your patient. BY the LITTLE information you have given I see that your patient has.... ineffective airway clearance related to asthma and cigarette smoking as evidenced by dyspnea with activity and altered respiratory rate (state what the respiratory rate was).

Other diagnosis that might apply as well....

Impaired Gas exchange

Activity intolerance

Bathing Self-Care deficit

Dressing Self-Care deficit

Feeding Self-Care deficit

The next one you show me what you have learned.

meonemine · Mar 28, 2017

the lungs had some wheezing the 02 stats were 95 with the oxygen on .patient didn't have difficulty coughing up sputum no edema Vital signs were ok

meonemine · Mar 28, 2017

ok..airway clearance related to bathing self care deficit as evidence by patient develops dyspnea while ambulatory bending over and a few ADL"so and the supporting assessment is obstruction of airway with blood and mucus,absent cough, and adventitious breath sounds

shan_elle · Mar 29, 2017

the lungs had some wheezing the 02 stats were 95 with the oxygen on .patient didn't have difficulty coughing up sputum no edema Vital signs were ok

Some words of advice...be much more specific in your assessment and reporting it to others. For example, you say your patient was satting at 95% with the O2 on. What rate was the O2 set at? What were they receiving the O2 through? There is a big difference between someone who needs 2L on a nasal cannula and someone who needs 15L on a non-rebreather. Saying vital signs are "ok" means nothing. What specifically was the BP? What specifically was the pulse rate, respirations, O2 sat, etc? When you report what the numbers are specifically it gives other healthcare providers a better picture of what's going on with the patient and how to adjust treatment, if needed.

Also, familiarize yourself with medical/nursing terms (this will come in time). I know it can be difficult to learn all the healthcare lingo, especially if you've never worked in healthcare, but you will be better received and save yourself some charting time. For example, you said "coughs up sputum which has blood in it." There is ONE word for that, "hemoptysis." You just saved yourself half a sentence and sound more professional. One thing that helped me was looking up every single word I didn't understand when reading my patient's chart. Good luck!

shan_elle · Mar 29, 2017

ok..airway clearance related to bathing self care deficit as evidence by patient develops dyspnea while ambulatory bending over and a few ADL"so and the supporting assessment is obstruction of airway with blood and mucus,absent cough, and adventitious breath sounds

"Airway clearance" (and I think you mean ineffective airway clearance) and "bathing self-care deficit" are BOTH nursing diagnosis so I don't believe you can use them in conjunction. Also, it doesn't make sense. As Esme12 mentioned, the "related to" is WHY they are having ineffective airway clearance. Does a bathing self-care deficit CAUSE ineffective airway clearance? (No.)

It almost sounds like you are trying to include the entire patient picture in one nursing diagnosis. You don't need to do that...that's why there are multiple "diagnoses" or "problems" that you will list, starting with the most acute. So, if we're using a nursing diagnosis of "ineffective airway clearance" focus more on factors that relate directly to the patient's lungs, breathing, oxygenation, and airway to help create your diagnosis. What has he been exposed to that could affect his airway? What vital signs did you observe that relate to the airway? What symptoms did you observe that made you think the patient might be having a difficult time clearing their airway?

meonemine · Mar 29, 2017

you have been a blessing thank you very much this is my first semester in nursing school