diagnosis

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.

Moved to nursing student assistance forum

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.....

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.

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

Do you have a care plan book? If not you need to buy one...ASAP. I use Ackley: Evolve Resources for Nursing Diagnosis Handbook, 11th Edition. The NANDA-I Nursing Diagnoses: Definitions and Classification 2015-2017 $23.76 on amazon is also one I use. Without a care plan reference book it is impossible to do care plans.

I gave you the diagnosis in my post. Ineffective airway clearance related to asthma and cigarette smoking as evidenced by dyspnea with activity and altered respiratory rate (state resp rate).

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

Ineffective airway clearance is one diagnosis (wheezing cough blood tinge sputum).

Bathing self care deficit is another diagnosis (dyspnea and weakness in shower).

Activity intolerance could be another nursing diagnosis (dyspnea and weakness with ambulation/bathing/bending over).

blood and mucus,absent cough

If your patient has an absent cough....how do you know he is coughing you blood tinged sputum?

For another example: Another possible diagnosis could be...

Activity intolerance (defined as: Insufficient physiological or psychological energy to endure or complete required or desired daily activities) related to (Bed rest; generalized weakness; imbalance between oxygen supply/demand; immobility; sedentary lifestyle) weakness and imbalance between oxygen supply/demand As Evidenced By (Defining characteristics: Abnormal blood pressure response to activity; abnormal heart rate response to activity; ECG change (e.g., arrhythmia, conduction abnormality, ischemia); exertional discomfort; exertional dyspnea; fatigue; generalized weakness) exertional dyspnea and generalized weakness with ADL's.

So the whole diagnosis would be something like this:

Activity intolerance related to weakness and imbalance between oxygen supply/demand As Evidenced By exertional dyspnea and generalized weakness with ADL's.

RELAX! Take a deep breath...it will get easier. What you need to be sure of is your assessment and being sure you have it all written correctly. TAKE YOUR TIME!

Use these critical thinking sheets to be sure you are getting the necessary data from your patient.

critical thinking flow sheet for nursing students

student clinical report sheet for one patient