Nursing Diagnosis help for patient with Interstitial Pneumonia and Mets to Bone

hm3 s. collins, spn said:

Help!
I have a pt admitted for interstitial pneumonia, and has anemia- low h&h and metastatic cancer of unknown origin, he has low prealbumin, protein malnutrition, hyponatremia, crackles in rll, inspiratory wheezes in rul, lul, and lll. He is on 12l o2 nc and has a o2 sat of 90-93%.

I have some nursing dx's thought of but not sure about the r/t part and which ones to use and in which order. I need 3.

Impaired gas exchange - what is the r/t part that I should include ?

Ineffective airway clearance- what is the r/t?

Imbalanced nutrition less than body requirements- what is the r/t part? The man has a normal bmi but has protein malnutrition!

Deficient knowledge r/t ? Aeb pt asking why he is on steroids,

Activity intolerance r/t ?

Chronic pain is r/t chronic disease process okay? He has met ca in his bones- high wbc, low rbc, low h&h barely low na+, and slightly high glucose- non fasting.

Can I use infection as a nursing dx or only risk for infection?

Any help would be greatly appreciated!

The first thing I need to do when I am helping anyone with their care plans is to go through the nursing process (which is what you should have been doing also). It helps organize you. I can't do step #1, the assessment because the patient and his medical records aren't in front of me, so I need to depend on the information that you've listed.

Step #2 of the process is to make a list of all the abnormal data. These are the symptoms (nanda calls them defining characteristics) that the patient has. These are important because they form the entire foundation of your resulting care plan. They are the basis for any nursing diagnoses you choose, the goals you decide upon and the nursing interventions you will order. That's pretty much the entire nuts and bolts of the whole care plan, so these symptoms are pretty important and you need to give them their just due.

Here's what I gather are your patient's symptoms:

• low h&h (what were the actual numbers?) - h&h is low in anemia, blood loss, chronic disease, when there has been hemorrhage, fluid retention or splenomegaly
• low prealbumin, also called transthyretin (what was the actual number) - may be an indicator of hepatic damage, malnutrition, disease of the liver, tissue necrosis or an acute inflammatory response
• slightly elevated non-fasting glucose (if the patient is on iv fluids with dextrose in them this may account for this)
• crackles in right lower lobe of lung
• inspiratory wheezes in right and left upper lobe, and the left lower lobe of the lung
• o2 sats of 90-93%
• chronic pain (where is this pain? what other descriptors do you have about this pain?)

Other information that is important to know is the patient's medical diagnoses. You need to know the pathophysiology of these conditions because it is through knowing the pathophysiology of the underlying medical conditions that you determine much of the r/t parts of your nursing diagnoses which is primarily what you asked in your post. The medical conditions are:

• interstitial pneumonia
• anemia
• metastatic cancer to the bone, origin unknown
• protein malnutrition
• hyponatremia

One of the things you should be doing before even approaching the writing of this care plan is looking up all the information you can find about these five conditions: their signs and symptoms, how the doctors diagnose them, and what the doctors generally order to treat the signs and symptoms of them as well as their underlying cause. That is going to answer some if not all of the questions you posed in your post. You can download and print out the critical thinking flow sheet for nursing students which is a form attached to the end of every one of my posts to help you organize this information for each medical diagnosis. This learning of information about medical diagnoses is crucial to your critical thinking and problem solving of patients problems.

The next part of step #2 is to take the list of your patient's symptoms and shop for nursing diagnoses. A diagnosis is the resulting decision or opinion you make after going through the process of examination or investigation of the facts. You did your examination and investigation of the facts in step #1 (assessment). When a doctor diagnoses someone with a medical condition, they do exactly the same thing. They do a review of systems (medical history) and physical examination of the patient and consider all the abnormal data before putting a medical diagnosis on them. We nurses need to be as careful about doing this as well. We have the nanda taxonomy (a big word meaning a classification--an arrangement or ordering of the nursing diagnoses into some kind of logical grouping) to help us out. So, you really need some kind of nursing diagnosis book as a reference to help you out here. I, personally, use nanda-I nursing diagnoses: definitions & classification 2007-2008 which is a small pocket book size and contains all the current 188 nursing diagnoses, their definition, the defining characteristics (symptoms) for each diagnosis, and the related factors (r/t's) for each diagnosis. Most fit on one or two pages. This is the same information that is included in most of the currently printed care plan or nursing diagnosis books on the market. The authors pay nanda a fee to use this information. These authors, however, add other goodies to their books, like nursing interventions and goals which is really what most people buy these books for. Most people overlook the nanda information. However, as students and new learners of how to diagnose, you really need to pay attention to it. Before you assign any nursing diagnosis and related factors to a patient you need to verify that it is meeting the nanda criteria for that particular diagnosis. If it isn't, then you've diagnosed it incorrectly and need to keep looking for another more appropriate nursing diagnosis.

Let me clear one question out of the way first. You asked:

Can I use infection as a nursing dx or only risk for infection?

Don't we know that this patient already has an infection: interstitial pneumonia? So, by default, you can't use risk for infection. Next, there is no nursing diagnosis of infection. Nanda considers that to be a medical diagnosis and we aren't going to step on doctor's toes here. The way nanda skirts around this issue of intruding into doctor's territory is to look at the patient's reaction to his medical condition. This is an important concept that is prevalent throughout nursing diagnosing. We don't diagnose medical conditions, but the patient's reaction to them. That means you are assessing their symptoms. So, what are the patient's reaction to, or symptoms of, the interstitial pneumonia? This is where your foray into some online resources and filling out a critical thinking flow sheet for nursing students comes in very handy. But, to help illustrate my point I'll help you out here. The symptoms of interstitial pneumonia are:

• high fever
• chills
• cough with purulent yellow or bloody sputum production
• dyspnea
• tachypnea
• crackles and decreased breath sounds
• pleuritic pain
• malaise
• there will also be:
  • infiltrates on the chest x-rays
  • normal or elevated wbcs
  • blood cultures that reveal a bacterial as a causative organism
  • varying arterial blood gas levels
  • reduced oxygen sat levels

Now, assuming that you are probably new at assessment, I would compare that list I just posted with what you remember observing in your patient and think about if you might have noticed any of these things and just didn't write them down. If so, add them to your patient's list of symptoms now. You won't have a nursing diagnosis of infection, but you will use your patient's symptoms to diagnose them with other problems that are related to the symptoms of this infection. See?

So, for the o2 sats of 90-93% you have impaired gas exchange. If you look at the related factors that nanda lists for this diagnosis (see this link: impaired gas exchange) you will find only two possibilities listed: alveolar-capillary membrane changes and ventilation perfusion imbalance. You need to know what each of those terms mean. Ventilation perfusion refers to gas exchange that occurs in the alveoli. In the case of pneumonia it doesn't occur efficiently (is imbalanced) because there is exudate and debris from the pneumonia interfering with the gas exchange. With interstitial pneumonia there may also have been some damage to the alveoli over time that has led to alveolar-capillary membrane changes. However, unless you have x-ray evidence or a statement by the doctor from the chart confirming this, I wouldn't use that. So, your nursing diagnostic statement should read: impaired gas exchange r/t ventilation perfusion imbalance aeb oxygen sats of 90-93%.

Now, you have other respiratory symptoms: crackles in right lower lobe of lung, and inspiratory wheezes in right and left upper lobe, and the left lower lobe of the lung. These you have correctly assigned with ineffective airway clearance. If you read the definition of this diagnosis, it says the following: inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. This is the underlying problem the patient should have for using this diagnosis. You mention nothing about this patient having a cough. If this inability to clear secretions from the airway is not the patient's problem then you're in the wrong nursing diagnosis. However, the crackles and wheezing suggest your patient does have an obstructed airway. So, what would be the underlying etiology (cause) of an obstruction in the airway of someone with pneumonia? Here is what nanda lists as the related factors are for this:

• airway spasm
• excessive mucus
• exudate in the alveoli
• foreign body in the airway
• presence of artificial airway
• retained secretions
• secretions in the bronchi

You know this patient better than I do. What do you think is the underlying reason for these adventitious breath sounds? My educated guess based on what I know about pneumonia would be either/or both excessive mucus and/or exudate in the alveoli (based on whether or not the patient is coughing and what they are coughing up). So, your diagnostic statement is going to look something like ineffective airway clearance r/t excessive mucus [and you could add, and exudate in the alveoli] aeb crackles in right lower lobe of lung, and inspiratory wheezes in right and left upper lobe and the left lower lobe of the lung.

You also have a patient in chronic pain. You didn't mention anything about where this pain is or what it is like. You really have to be more specific. What I know of cancer that has spread to the bones is that it is quite painful. There are also special precautions that have to be taken with people who have bone metastasis. These bones are subject to pathological fractures. These patients are also subject to impaired mobility. And, I am not so sure that chronic pain is an appropriate a diagnosis to use as would be acute pain in this case. Acute pain is defined as . . .A duration of less than 6 months. Chronic pain is defined as . . .A duration of greater than 6 months. You would only know this from a review of the patient's medical record and an interview with the patient. The related factor for his pain is his cancer and you can legitimately say that in your diagnostic statement: acute [or chronic] pain r/t metastatic cancer aeb [the specific signs and symptoms of the pain].

Don't know where you're getting the imbalanced nutrition: less than body requirements, deficient knowledge (specify), or activity intolerance from because you didn't list any symptoms to support any of them. I can't help determine related factors without the defining characteristics.

Lastly, you titled your post, diagnosis prioritization. Prioritization is done by the patient's most important needs. Keep in mind that the care plan is a problem solving process, so each nursing diagnosis is actually a patient problem. You list the problems in the order of which is most important of needing attention first. Most instructors suggest prioritizing by maslow's hierarchy of needs. The hierarchy from most important to least important is as follows:

1. physiological needs (in the following order)
   • the need for oxygen and to breathe
   • the need for food and water
   • the need to eliminate and dispose of bodily wastes
   • the need to control body temperature
   • the need to move
   • the need for rest
   • the need for comfort
2. safety and security needs (in the following order)
   • safety from physiological threat
   • safety from psychological threat
   • protection
   • continuity
   • stability
   • lack of danger
3. love and belonging needs
   • affiliation
   • affection
   • intimacy
   • support
   • reassurance
4. self-esteem needs
   • sense of self-worth
   • self-respect
   • independence
   • dignity
   • privacy
   • self-reliance
5. self-actualization
   • recognition and realization of potential
   • growth
   • health
   • autonomy

By this hierarchy, the diagnostic statements that I did for you would be prioritized and listed this way:

1. Impaired gas exchange r/t ventilation perfusion imbalance aeb oxygen sats of 90-93%.
2. Ineffective airway clearance r/t excessive mucus [and you could add, and exudate in the alveoli] aeb crackles in right lower lobe of lung, and inspiratory wheezes in right and left upper lobe and the left lower lobe of the lung.
3. Acute [or chronic] pain r/t metastatic cancer aeb [the specific signs and symptoms of the pain].