Help Choosing a Nursing Diagnosis.

[simply_viki]

just for reference (I don't think I need the whole thing broken down for me, I have to do the work myself or I'll never learn anything, I just need help with the diagnosis part), here is the scenario I have been given. I have no other info than this. I've put in red the things I've identified as possible problems, if I've missed any let me know.

"joseph, a white male in his mid 30s, comes to the free clinic because of a cough that he's had for several months. he says he also "sweats at night" no matter what temperature it is outside. he is homeless and currently stays at the local community outreach center. he has no family members in the area. his clothing is dingy but not ragged, and he is wearing shoes and a coat. further questions reveal he has lost 50 pounds in the past 3 months. palpation reveals decreased chest expansion, percussion is dull over bases, and auscultation reveals diminished breath sound bilaterally. crackles are present over upper lobes and there is persistent coughing. orders include:

1. regular diet

2. tylenol 500 mg po q 4 hrs PRN

3. robitussin 2 teaspoons q 4-6 hrs PRN

4. sputum culture"

I'm stuck between "ineffective airway clearance" and "nutrition: less than body requirements". I know that the airway one is the priority, but I'm having such a hard time finding the related factor. I'd like to say related to fluid in the lungs, but I don't know for an absolute fact that the crackles and coughing are due to fluid (maybe because I'm a new student and having a hard time making those connections), but on the other hand, I know that the doctor prescribed robitussin, an expectorant, so it seems reasonable to assume that there is fluid. is it? what am I missing here?

for the nutrition one, really the only bit of evidence I have for that is the loss of 50 pounds in the last three months, and I can't seem to make that fit the defining characteristics, because the only two defining characteristics even close are: "body weight 20% or more under ideal weight", and "loss of body weight despite adequate food intake". both of those involve making big assumptions though - I don't know how much my patient weighed before, and I don't know what his ideal weight is, so I don't know if he is now 20% or more under his ideal weight. and I don't know if my patient lost all that weight despite adequate food intake, or if he was starving because he's homeless (which seems more likely, but I have no idea what is a good nursing diagnosis for starvation due to insufficient funds for food).

help! I gave up on this last week after an unsuccessful brainstorming session, and after sleeping on it and pondering over it and poring over my books, I still haven't gotten anywhere with it, and it's due Saturday! (and not just the diagnoses either, a mini care plan, and answers to a few questions.

[CapNurse09]

It sounds like your guy has TB (tuberculosis)

Our med surg text gives these diagnoses that may fit your scenario

Ineffective airway clearance r/t increased secretions

Imbalanced nutrition

Look up TB in a med surg text and I hope this helps you some.

[simply_viki]

But am I supposed to look for a medical diagnosis? I'm so confused. I thought of pneumonia, and my classmate thought of TB, but ultimately at the end of the semester, we're supposed to take an exam consisting of one of these scenarios, and we're supposed to come up with a nursing diagnosis and care plan using no books or other materials. I think looking for medical diagnosis would get me sidetracked from becoming able to pass that final exam, because I know I can't memorize the signs and symptoms of all the diseases and conditions that might be in the scenarios given for the exam. I'm not even sure how I'll be able to memorize the info for the nursing diagnoses.

Sorry, I don't mean to bash your help, I think I got sidetracked venting. Thank you, I will check in my med surg book again.

[Daytonite, BSN, RN]

1. Ineffective breathing pattern r/t respiratory muscle fatigue aeb decreased chest expansion
2. Ineffective airway clearance r/t retained secretions aeb percussion is dull over bases, auscultation reveals diminished breath sound bilaterally, crackles are present over upper lobes and persistent coughing
3. Imbalanced nutrition: less than body requirements r/t illness and homelessness aeb lost 50 pounds in the past 3 months
4. Impaired home maintenance r/t no family or financial support aeb homelessness, has no family in the area, wearing clothing [shoes and a coat] that is dingy (needs washing?)
5. Risk for infection r/t possible exposure to communicable disease [this are why he is having the night sweats and the weight loss--he's probably got tb]

I'm stuck between "Ineffective airway clearance" and "Nutrition: less than body requirements". I know that the airway one is the priority, but I'm having such a hard time finding the related factor. I'd like to say related to fluid in the lungs, but I don't know for an absolute fact that the crackles and coughing are due to fluid (maybe because I'm a new student and having a hard time making those connections), but on the other hand, I know that the doctor prescribed robitussin, an expectorant, so it seems reasonable to assume that there is fluid. Is it? What am I missing here?

The crackles tell you there is loose "Stuff" in the lungs capable of being coughed out. The cough is because he is trying to get it out. The diminished breath sounds are areas of the lungs that are blocked with secretions where air can't even get in, so you can't hear any air exchange at those areas at all.

For the nutrition one, really the only bit of evidence I have for that is the loss of 50 pounds in the last three months, and I can't seem to make that fit the defining characteristics, because the only two defining characteristics even close are: "Body weight 20% or more under ideal weight", and "Loss of body weight despite adequate food intake". Both of those involve making big assumptions though - I don't know how much my patient weighed before, and I don't know what his ideal weight is, so I don't know if he is now 20% or more under his ideal weight. And I don't know if my patient lost all that weight despite adequate food intake, or if he was starving because he's homeless (which seems more likely, but I have no idea what is a good nursing diagnosis for starvation due to insufficient funds for food).

You have to look at the other evidence. He's 30 years old, homeless, has had a cough for several months, dingy clothing to me sounds like it hasn't been washed for a while, has had this cough for several month, has night sweats and the doc ordered a sputum culture. Infection is flashing in my mind in big red letters and tb is probably what is going on. When people get chronic respiratory infections they lose weight. More symptoms could have been included in the scenario, but they are just giving you some teasers here.

[simply_viki]

Would it be OK to word it "Ineffective Airway Clearance R/T lung impairment" or "Ineffective Airway Clearance R/T impaired lung function" or something like that? How much leeway to we have in the wording?

[Daytonite, BSN, RN]

simply_viki said:

Would it be OK to word it "ineffective airway clearance r/t lung impairment" or "ineffective airway clearance r/t impaired lung function" or something like that? How much leeway to we have in the wording?

The taxonomy lists the following related factors for this diagnosis (page 308, NANDA international nursing diagnoses: definitions and classifications 2009-2011)

• environmental
  • second-hand smoke
  • smoke inhalation
  • smoking

• obstructed airway

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

• physiological

  • allergic airways
  • asthma
  • chronic obstructive pulmonary disease
  • hyperplasia of the bronchial walls
  • infection
  • neuromuscular dysfunction

So, if you want to use a related factor (etiology) of "lung impairment" I would try to make it conform as closely to one of the categories listed under the related factors, probably one of the physiological ones, without actually using a medical disease or condition and getting as specific as possible.

TB would be an inflammation of the lung tissue, but no infection (inflammation) has been confirmed yet.

[simply_viki]

(By the way, you might wonder why I'm focusing on Airway Clearance instead of Impaired Breathing - my professors aren't looking so much for a priority at this level as much as they want to see that we can think through a care plan, and I'm more comfortable going with what has the most evidence)

OK, so fluid in the lungs. How do we know it's fluid in the lungs? I looked up each of those signs, and according to my textbooks, they can all mean different things.

Dullness - Can mean abnormal density, as with pneumonia, pleural effusion, atelactasis, or tumor.

Diminished breath sounds - Means airflow is decreased by bronchial obstruction (atelactasis), or fluid (pleural effusion) or tissue (obesity) separates the air passages from the stethoscope.

Crackles - Secondary to fluid in the airways or alveoli or to opening of collapsed alveoli.

Coughing - Well... I don't have any cute little blurbs on coughing, just pages and pages of info. Can indicate physical obstruction, irritation, or fluid, as far as I can tell.

Anyway, how do we know that each one of those don't mean something other than retained secretions? (I believe you, I am just trying to understand).

[Daytonite, BSN, RN]

simply_viki said:

Anyway, how do we know that each one of those don't mean something other than retained secretions? (I believe you, I am just trying to understand).

I don't. It was just an educated guess on my part. Go with what you feel is the best answer since you are looking everything up. I didn't do that. It is more important that you understand how to work with the diagnoses.

[simply_viki]

Hmm, OK thanks.

Well, I don't think an educated guess can hurt - that's all I'm going to be able to rely on for the test at the end of the semester. They're going to give us a scenario and expect us to answer several questions about it and make a diagnosis and care plan without using any books or other resources, so I'm pretty desperate to learn how to think and process these things.

[Daytonite, BSN, RN]

What I would do is look at the taxonomy (definition, defining characteristics, and related factors) over and over for certain commonly used diagnoses until I became familiar with it. When I made a list of this patient's symptoms in your scenario I recognized that several of them were ineffective airway clearance right away. When I saw the "Decreased chest expansion" I thought of ineffective breathing pattern right away and I re-read the scenario to see if there was another symptom that I might have missed or a etiology for it. This is because I am so used to working with respiratory patients and the respiratory nursing diagnoses. For respiratory there are 3:

• impaired gas exchange
• ineffective airway clearance
• ineffective breathing pattern

For circulation and heart there is really only one:

• decreased cardiac output - strictly heart arrhythmias and heart failure
• sometimes, ineffective tissue perfusion, cardiopulmonary - this includes the lungs along with the heart and involves situations where there are problems with oxygenation of the specific lung tissue itself as in blood clots lodged in the arteries of the lungs causing cell death

Do you know where to find the taxonomy information?

• nursing diagnosis books have this information
• many authors of care plan and nursing diagnosis books include this nanda taxonomy information with the nursing diagnoses. this information will usually be found immediately below the title of a nursing diagnosis.
• the nanda taxonomy information is in the appendix of taber's cyclopedic medical dictionary

My copy of nanda international nursing diagnoses: definitions and classifications 2009-2011 classifies the nursing diagnoses into physiological classes.

The only thing I can thing of is, perhaps, to make flashcards to help memorize the defining characteristics and related factors of these diagnoses. The difference between medical diagnoses and nursing diagnoses, as you will see as you study them, is that the data supporting our diagnoses include patient impressions and responses that may be subjective which is very different from medical diagnoses which are very objective symptoms. Keep in mind that as nurses we treat the patient's responses to the medical diseases and conditions. That is a huge concept of nursing care planning and problem solving that we must never forget.

[simply_viki]

I think the card I have that lists the NANDA diagnoses is arranged in order of taxonomy. I'll have to check when I get home.

I have to come up with a short-term goal. I am thinking about using something like "Patient will demonstrate 2 effective coughing techniques by the end of the day". Do I have to be more specific than that? Also, I have to come up with at least 6 interventions - do they have to all be directly related to the goal, or just the diagnosis? Should I have a more broad goal?

Thanks Daytonite - I really appreciate your help on these things.

[Daytonite, BSN, RN]

simply_viki said:

I think the card I have that lists the NANDA diagnoses is arranged in order of taxonomy. I'll have to check when I get home.

I have to come up with a short-term goal. I am thinking about using something like "Patient will demonstrate 2 effective coughing techniques by the end of the day". Do I have to be more specific than that? Also, I have to come up with at least 6 interventions - do they have to all be directly related to the goal, or just the diagnosis? Should I have a more broad goal?

Thanks Daytonite - I really appreciate your help on these things.

What diagnosis are you referring to? Goals are specific to a diagnosis.