Help with nursing diagnosis

[bowenchelsea]

Mrs. F., a 92 year-old widow, is found with a significantly decreased level of consciousness in her apartment. She is admitted to the ER with a pulse oximeter reading of 76% and a respiratory rate of 24 that are shallow and course. Upon auscultation, the lung sounds in the bases are diminished with crackles heard throughout the lung fields. After a diagnosis of pneumonia and beginning a regimen of antibiotics, as well as being placed on O2 at 4 liters/minute, she starts to become alert and oriented. However, after 2 days of treatment, she still needs to rest after getting up to go to the bathroom. She is unable to make a full lap around the nurse's station without sitting for short periods of time due to being short of breath. She states that this is abnormal for her since she usually spends a great deal of time gardening outside and does not get tired.

Nursing Diagnosis: (THIS IS WHAT I THINK IT IS..I AM NOT SURE)

Impaired gas exchange due to dyspnea on exertion, lethargy and fatigue, and decreased oxygen content, decreased oxygen saturation secondary to infection as evidenced by decreased level of consciousness, pulse oximeter reading of 76% and a respiratory rate of 24 that are shallow and course and the lung sounds in the bases are diminished with crackles. Two days after antibiotics, starting to become alert and orientated and a need to rest and to sit for short periods of time due to shortness of breath.

(THESE ARE MY OPTIONS TO CHOOSE FROM:)

Ineffective Airway Clearance

Fatigue

Imparied Gas Exchange

Sedentary Lifestyle

Risk for Ineffective Respiratory Function

Ineffective Peripheral Tissue Perfusion

[Muffy5]

I agree with you that impaired gas exchange is the best diagnosis, but remember the r/t needs to be the physiologic reason. So with pneumonia it is due to consilidation/mucus. The dyspnea,fatigue, low 02 sats, restlessness, decreased LOC are actually your evidence.

impaired gas exchange r/t ------------AEB--------------.

Hope that helps!

[Elle_Guerira]

Remember the acronym PES when doing your Nsg. Dx: P (Problem), E (Etiology), S (S/Sx.):

P - Since the pt. has a med. dx. of pneumonia, the priority nsg. dx. of impaired gas exchange is an excellent choice (remember your ABCs). Another priority choice would be ineffective airway clearance.

E - After you've identified your problem, make sure to put related to or r/t afterwards. You can't put a med. dx. as your etiology, therefore it's helpful to know what the pathophysiology of the disease is when stating your etiology.

S - After your etiology, use as evidenced by or AEB before you list the clinical manifestations.

Therefore based on your case study, I would write out my nsg dx as:

Impaired gas exchange r/t decreased functional lung tissue AEB SpO2 of 76%, dyspnea, crackles heard in lung bases & a RR of 24, labored

Other potential nsg. dxs. I would use:

- Ineffective breathing pattern

- Fatigue

- Potential for sepsis

Hope it makes sense :)

[mevans40]

Hello everyone....I am in need of some desperate help with a nursing care plan and I have no idea where to start. This is my very first care plan and I need assistance. It was not explained well at all. Someone advised this website to me and they came out with an "A" on their nursing care plan. They were in the same situation I was in....HELP!!!!

My pt. 6 yr. old male

admitting dx: HB-SS Disease w/crisis

Complaint: back pain and leg pain R/T Diagnosis of Sickle Cell Anemia

He has had appendix and gall bladder removed

He was also on incentive spirometer.

He wouldn't urinate until after I left.

Very withdrawn...only to nurses, not parents.

Wouldn't eat or hardly drink.

Had IV with Vanco 300 mg/100NSCC Q 24HRS

I have to have (4) nursing problems thay must be prioritized and include subjective and objective data as well as a correctly stated current (NANDA approved) nursing diagnosis. The four problems must include (1) physical, (2) psychosocial, (3) teaching and (4) a potential problem or a high-risk problem. I was only with this pt. for 1 day and then he was discharged. I need dx., pt. goals, interventions, implementation. HELP!!!! I need to know how to organize.