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.

[simply_viki]

Ineffective Airway Clearance.

[Daytonite, BSN, RN]

Your goal must be reflective of your interventions. Your interventions must focus on treating the symptoms. This patient is coming in with several months of coughing and crackles in his lungs. That is a primary focus for this diagnosis. I will help you with this one.

The diagnosis is 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.

Short-term goal

(is what you predict will happen as a result of the interventions being performed): patient will demonstrate how to correctly cough and deep breath by the end of the day.

Interventions

(they have to address the aebs and the r/ts):

• assess level of consciousness and orientation to person, place and time
• inspect the chest for abnormal movements with breathing
• inspect the extremities for cyanosis, edema and clubbing of the digits
• auscultate the lungs for diminished, absent and adventitious breath sounds q shift
• monitor for increasing lethargy
• have the patient sit upright to ease their breathing
• encourage the patient to drink plenty of fluids to stay hydrated and use humidification
• give oxygen, bronchodilators, mucolytics, expectorants and antibiotics as ordered and as needed
• explain the importance of coughing and deep breathing
• teach coughing and deep breathing exercises

Coughing

• take a slow deep through the nose and expand the chest fully
• breathe out through the mouth feeling the chest sink down and in
• take a second slow breath through the nose expanding the chest fully and breathing out
• take a third breath in the same way but hold it
• the patient should now cough two or three times (once is usually not enough) and concentrate on using the diaphragm to force the air out
• follow with several normal breaths exhaling slowly
• do this every 2 hours

 

Deep Breathing

• lie supine with legs slightly bed at the knees; can also be done sitting and standing
• take as deep breath as possible through the nose and allow the abdomen (not the chest) to rise
• hold the breath for a count of five
• exhale completely through pursed lips as if whistling allowing the ribs to sink downward and inward
• rest several seconds and repeat 5 to 10 times every hour
• teach about the underlying diagnosis and treatment plan