Nursing Dx?

[Gigglesforall, BSN, RN]

Okay, so I'm working on my first care plan and was looking for some advice as to what the primary nursing Dx for my patient should be. She is a 53 year old moderately obese woman who came into the ER c/o sob and coughing up green sputum. She felt as though a vice was around her chest preventing her from breathing. Her vitals were all WNL, R 20, O2 sats were 95, BP 114/81, and P 88. In obtaining her Hx I found out she frequently experiences sob and has cardiomegaly, so the physicians were suspecting her problem was heart-related, but I wasn't able to stay long enough with my patient before they made the actual medical Dx. The nurse said her EKG looked normal. My patient stated she gets tired after walking or standing longer than ten minutes. She also has arthritis in her back, which prevents her from lying flat so she sleeps in her recliner. I think that's pretty much the extent of the info I got on her. I really wanted to go in the direction of activity intolerance or even risk for activity intolerance, but then my clinical instructor said she would lean more towards ineffective airway clearance related to mucous something or other a.m.b. sob and cough. Part of my assignment was to ask her an ungodly amount of questions, and she didn't seem too tired or short of breath in answering my questions. In fact, I myself couldn't see any symptoms of the shortness of breath. I don't see many outcomes that really coincide with the airway clearance diagnosis, but I suppose I could make a few of them work. What do you guys think I should do?

[Jenn_RN]

Definitely airway. I am no expert (1st semester), but in my opinion, airway is most important because most adl's require more effort from her than a question/answer interview that you witnessed, and that in turn affects her mobility, nutrition, autonomy, etc on a daily basis. If you can't breathe, you really can't do anything...yk? Also, with the sputum, she'd have a risk of aspiration. So for interventions, you could deep breathe and cough, bed at 30 degree angle, maybe send sputum to lab since it's green? I'd say increase fluids, but with her cardiomegaly, I wonder if that might be contraindicated...like I said I am just first semester myself.

I know in my school, they look for the major diagnosis, but want others as well if the problems are there...so maybe you could include a sub nursing diagnosis of activity intolerance and/or other things you see as important. I know my instructors would rather too much than too little...it shows you are really thinking it through.

good luck and I hope I've helped. :)

[renerian, BSN, RN]

Sounds like a winner to me in the absense of having more data.

renerian

[ShandyLynnRN, BSN, RN]

airway, altered breathing, sounds good to me.

[Gigglesforall, BSN, RN]

Thanks everyone, I'm definitely going that route now. It's good to have the reinforcement!

[emily_mom]

Airway definitely. Does she smoke?

[Gigglesforall, BSN, RN]

She quit three years ago, but was a pack a day smoker for approximately 30 years.

[KimRN03]

Definately airway! When I am looking for Nursing Dx I go with the ABC's first....Airway, Breating, Circulation. You will never go wrong thinking along those lines.