I have the nsg dx but can't figure ou the r/t. Help?

[DroogieRN]

I have my first real care plan due tomorrow on my actual clinical patient (I've done one on a hypothetical pt already). My nsg dx is "ineffective airway clearance," but I can't figure out what to put for "related to." My patient has COPD but I can't use a medical dx. She's 90 with alzheimer's and on O2 and that's the majority of what I know about her.

Would anyone have any ideas? Any help is appreciated. Thanks for any input.

[MBA2RN, BSN, RN]

These are all nursing diagnoses associated with COPD (excerpted from F.A. Davis' Nursing Care Plans, 7ed).

impaired Gas Exchange may be related to altered O2 delivery (obstruction of airways by secretions/bronchospasm, air trapping) and alveoli destruction, possibly evidenced by dyspnea, restlessness, confusion, abnormal ABG values, and reduced tolerance for activity.

ineffective Airway Clearance may be related to bronchospasm, increased production of tenacious secretions, retained secretions, and decreased energy/fatigue, possibly evidenced by presence of wheezes, crackles, tachypnea, dyspnea, changes in depth of respirations, use of accessory muscles, cough (persistent), and chest x-ray findings.

Activity Intolerance may be related to imbalance between O2 supply and demand, and generalized weakness, possibly evidenced by verbal reports of fatigue, exertional dyspnea, and abnormal vital sign response.

imbalanced Nutrition: less than body requirements may be related to inability to ingest adequate nutrients (dyspnea, fatigue, medication side effects, sputum production, anorexia), possibly evidenced by weight loss, reported altered taste sensation, decreased muscle mass/subcutaneous fat, poor muscle tone, and aversion to eating/lack of interest in food.

risk for Infection: risk factors may include decreased ciliary action, stasis of secretions, and debilitated state/malnutrition.

[Daytonite, BSN, RN]

diagnosing requires a logical approach to problem solving that involves analysis. in other words, we must systematically break down the information obtained from a patient's medical history, physical examination, and laboratory test results and then reassemble it into a pattern that fits a well-defined syndrome (a group of symptoms that collectively describe a nursing diagnosis). has, not upon their medical diagnosis.

why did you decide this patient had ineffective airway clearance? what symptoms did she have? the definition of this diagnosis is "inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway." (page 5, nanda-i nursing diagnoses: definitions & classification 2007-2008) so, this would indicate that the cause ("related to") of the ineffective airway clearance is what is making the airway obstructed. this webpage contains a list of what those thing can be (see the related factors): [color=#3366ff]ineffective airway clearance knowing the pathophysiology of copd also will help you choose the related factor as well. actually copd can be used since it is not really a medical diagnosis.