diagnosis

Esme12, ASN, BSN, RN · 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

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