Published Feb 15, 2009
ManderRN
18 Posts
Hello, I am a first year nursing student and I need 3 ideas for care plans from my client from clinicals this past week. My client was diagnosed with pneumonia, and already has COPD. She also has a history of lung cancer. Client has had frequent bouts of pneumonia already this year. However, her vital signs were mostly WNL when I assisted caring for her. Her respirations were at 20, and O2 sats were at 100 with 4 L of 02. She did have high blood pressure, with the first reading at 164/87, and the second at 185/101. She was alert and oriented, eating and drinking well, and walking with assistance. She had little risk for skin breakdown as she was moving frequently, and she had a PRN adapter, but was no longer on the IV. She was coughing frequently, and productively. She was on medication for pain, with a pain level of 7, so I already have:
Risk for falls related to presence of acute illness and use of narcotics for pain.
Pain related to pneumonia as evidenced by pt. states pain is at a level 7 on a scale of 1-10.
What should I do for her third diagnoses? I am thinking ineffective airway clearance, or impaired gas exchange, but at the time that I cared for her, I collected no data to suggest (besides the productive cough) that these two things were still happening. I appreciate any advice anyone has to give! Thanks in advance.
Daytonite, BSN, RN
1 Article; 14,604 Posts
i would definitely give a copder with pneumonia who had a frequent productive cough a diagnosis of ineffective airway clearance r/t chronic obstructive pulmonary disease and lung inflammation aeb frequent productive coughing. the fact that they keep coughing means that the airways are still congested. did you happen to get a listen to her breath sounds? wheezes, rales and/or rhonchi are symptoms of this diagnosis. see
pain related to pneumonia as evidenced by pt. states pain is at a level 7 on a scale of 1-10.
Thank you for your help! :)
Valasca
89 Posts
I would add Imparied gas exchange r/t pneumonia
i would add imparied gas exchange r/t pneumonia
and, i will add, again, that pneumonia is a medical diagnosis and cannot be used as a related factor in a diagnostic statement this way. impaired gas exchange has 2 related factors:
when someone with copd and has impaired gas exchange (excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane) they already have permanent changes that have occurred in the walls of their alveoli causing gas exchange problems. if they get pneumonia it contributes to it more. the correct nursing diagnostic statement for a patient with copd and pneumonia is:
these ways explain the etiology of the gas exchange problem.
Psy_sci, BSN, RN
19 Posts
Is COPD not also a medical dx.? I see it in my med-surg Dx. book, and am trying to figure out how to word it properly.
I am trying to come up with 3 nursing dx. for a pt. who didn't have any problems at the time I was with him, but came in with SOB and angina, but now is in no pain, and on 4L oxygen, he has no distressful symptoms at all. BUT, he has some abnormal abg's, like pH of 7.48, pco2 of 29, and PO2 of 105. His labs also indicated K- 5.6, BUN of 47, WBC- 15.1, RBC's 3.98. He also has hx. of CAD, HTN, COPD, carotid stenosis, ventricular fibrillation arrest. MI is r/o, and the dr.'s note said he has CHF.
He did have some fine crackles in RLL, and mild edema in LE, but then I find he has poor skin turgor, dry skin, and admits to not drinking water often, so I see some evidence of dehydration, coupled with my increased K and BUN. I decided to go with one Dx. of FVD r/t lack of adequate fluid intake aeb poor skin turgor, dry skin,pt's verbalization of "not drinking water often", and increased K and BUN.
I'm also attempting Impaired Gas exchanged r/t "NOT SURE WHAT TO PUT HERE"-because of COPD being a med. dx, I know my prof. will not accept it, so is their another way I can word it? ....then following up with aeb abnormal abg's and elevated pH. Is this a correct dx., with the angle I am going for?
Finally, I would like to address his cardiopulmonary issues, but the only evidence I have is "EKG shows sinus rhythm w/possible interior infarct age undetermined and nonspecific ST-T changes" and "a 2/6 pansystolic murmur at the base" which I don't know how to interpret. I was thinking "Ineffective tissue perfusion", and wondering what else I can use. Again, his RBC's are low, he has diminished pedal pulses, mild peripheral edema, and fine crackles. My professor will only let us use one AEB!! So I have to choose between cardiopulmonary and peripheral!
And I need to select a priority dx., so would the Impaired gas exchange automatically be my choice since respiratory generally takes priority, even though he presently wasn't having a breathing issue?
Any help would be great!! I'm kinda lost here:banghead:
is copd not also a medical dx.? i see it in my med-surg dx. book, and am trying to figure out how to word it properly.i am trying to come up with 3 nursing dx. for a pt. who didn't have any problems at the time i was with him, but came in with sob and angina, but now is in no pain, and on 4l oxygen, he has no distressful symptoms at all. but, he has some abnormal abg's, like ph of 7.48, pco2 of 29, and po2 of 105. his labs also indicated k- 5.6, bun of 47, wbc- 15.1, rbc's 3.98. he also has hx. of cad, htn, copd, carotid stenosis, ventricular fibrillation arrest. mi is r/o, and the dr.'s note said he has chf. he did have some fine crackles in rll, and mild edema in le, but then i find he has poor skin turgor, dry skin, and admits to not drinking water often, so i see some evidence of dehydration, coupled with my increased k and bun. i decided to go with one dx. of fvd r/t lack of adequate fluid intake aeb poor skin turgor, dry skin,pt's verbalization of "not drinking water often", and increased k and bun.i'm also attempting impaired gas exchanged r/t "not sure what to put here"-because of copd being a med. dx, i know my prof. will not accept it, so is their another way i can word it? ....then following up with aeb abnormal abg's and elevated ph. is this a correct dx., with the angle i am going for?finally, i would like to address his cardiopulmonary issues, but the only evidence i have is "ekg shows sinus rhythm w/possible interior infarct age undetermined and nonspecific st-t changes" and "a 2/6 pansystolic murmur at the base" which i don't know how to interpret. i was thinking "ineffective tissue perfusion", and wondering what else i can use. again, his rbc's are low, he has diminished pedal pulses, mild peripheral edema, and fine crackles. my professor will only let us use one aeb!! so i have to choose between cardiopulmonary and peripheral!and i need to select a priority dx., so would the impaired gas exchange automatically be my choice since respiratory generally takes priority, even though he presently wasn't having a breathing issue?any help would be great!! i'm kinda lost here
i am trying to come up with 3 nursing dx. for a pt. who didn't have any problems at the time i was with him, but came in with sob and angina, but now is in no pain, and on 4l oxygen, he has no distressful symptoms at all. but, he has some abnormal abg's, like ph of 7.48, pco2 of 29, and po2 of 105. his labs also indicated k- 5.6, bun of 47, wbc- 15.1, rbc's 3.98. he also has hx. of cad, htn, copd, carotid stenosis, ventricular fibrillation arrest. mi is r/o, and the dr.'s note said he has chf.
he did have some fine crackles in rll, and mild edema in le, but then i find he has poor skin turgor, dry skin, and admits to not drinking water often, so i see some evidence of dehydration, coupled with my increased k and bun. i decided to go with one dx. of fvd r/t lack of adequate fluid intake aeb poor skin turgor, dry skin,pt's verbalization of "not drinking water often", and increased k and bun.
i'm also attempting impaired gas exchanged r/t "not sure what to put here"-because of copd being a med. dx, i know my prof. will not accept it, so is their another way i can word it? ....then following up with aeb abnormal abg's and elevated ph. is this a correct dx., with the angle i am going for?
finally, i would like to address his cardiopulmonary issues, but the only evidence i have is "ekg shows sinus rhythm w/possible interior infarct age undetermined and nonspecific st-t changes" and "a 2/6 pansystolic murmur at the base" which i don't know how to interpret. i was thinking "ineffective tissue perfusion", and wondering what else i can use. again, his rbc's are low, he has diminished pedal pulses, mild peripheral edema, and fine crackles. my professor will only let us use one aeb!! so i have to choose between cardiopulmonary and peripheral!
and i need to select a priority dx., so would the impaired gas exchange automatically be my choice since respiratory generally takes priority, even though he presently wasn't having a breathing issue?
any help would be great!! i'm kinda lost here
copd stands for chronic obstructive pulmonary disease. it is a general term that doctors use to describe a variety of diseases that result in obstruction of the airways. the 4 most common diseases are:
nanda (the north american nursing diagnosis association) recognizes it as a general term so copd is able to be used as a related factor in nursing diagnostic statements. the four respiratory diseases listed above, however, are not.
"ekg shows sinus rhythm w/possible interior infarct age undetermined and nonspecific st-t changes" and "a 2/6 pansystolic murmur at the base" which i don't know how to interpret. i was thinking "ineffective tissue perfusion", and wondering what else i can use. again, his rbc's are low, he has diminished pedal pulses, mild peripheral edema, and fine crackles. my professor will only let us use one aeb!! so i have to choose between cardiopulmonary and peripheral!
fvd r/t lack of adequate fluid intake aeb poor skin turgor, dry skin,pt's verbalization of "not drinking water often", and increased k and bun.
Thanks Daytonite!
Your explanation really cleared things up, I guess I just needed to understand some of the pathophys. a little better, and I think your wording really made it more understandable.
I'm sorry I messed up, my instructor only wants us to use one R/T factor, but we can use many AEB's. It was very late:rolleyes:
You probably won't see this in time since I have to turn this in in 2 and a half hours, but it sounds like maybe the Decreased cardiac output would be the priority, even though he was in no acute distress. His HR was 66. I didn't list any normal results, though I guess his heart rate is on the low side. Incidentally, his sodium was 134, low, but barely...
and his HC03 was 21.9, so normal.
Either way, hearing your thoughts would be helpful in understanding my pt.!
thanks daytonite!your explanation really cleared things up, i guess i just needed to understand some of the pathophys. a little better, and i think your wording really made it more understandable.i'm sorry i messed up, my instructor only wants us to use one r/t factor, but we can use many aeb's. it was very late:rolleyes:you probably won't see this in time since i have to turn this in in 2 and a half hours, but it sounds like maybe the decreased cardiac output would be the priority, even though he was in no acute distress. his hr was 66. i didn't list any normal results, though i guess his heart rate is on the low side. incidentally, his sodium was 134, low, but barely...and his hc03 was 21.9, so normal.either way, hearing your thoughts would be helpful in understanding my pt.!
your explanation really cleared things up, i guess i just needed to understand some of the pathophys. a little better, and i think your wording really made it more understandable.
i'm sorry i messed up, my instructor only wants us to use one r/t factor, but we can use many aeb's. it was very late:rolleyes:
you probably won't see this in time since i have to turn this in in 2 and a half hours, but it sounds like maybe the decreased cardiac output would be the priority, even though he was in no acute distress. his hr was 66. i didn't list any normal results, though i guess his heart rate is on the low side. incidentally, his sodium was 134, low, but barely...
and his hc03 was 21.9, so normal.
either way, hearing your thoughts would be helpful in understanding my pt.!
prioritize by maslow. each of the diagnoses has a definition that goes with the label (what you call the nursing diagnosis). impaired gas exchange should go first because it involves oxygen/carbon dioxide exchange. a person's brain can only live 4 minutes if the lungs fail to provide enough oxygen. the heart cells can live a little longer. it takes heart tissue a little longer to die without oxygen. remember abcs--airway, breathing, circulation. i talked about your diagnoses in the order they belonged. you can add all the evidence you want to them, but consult online diagnosis pages to assure you are putting correct symptoms with the right diagnoses. you can find diagnosis pages for each of these of these 3. look for the defining characteristics which is what nanda calls the symptoms. they are listed right under the diagnosis name. see here: http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
duckoutofwater
5 Posts
Hello everyone, I am in the middle of my first care plan. Its due Tuesday and I'm getting a bit confused (maybe thinking out it too much). Is the "related to" for the nursing diagnosis? or the intervention you plan to do? Also I've been doing my hardest to find a simple phyiology for pneumonia, not too lengthy or complicated. Hope you can help. Please email me too if you have anything, I sure would appreciate it. wheW!
p.s. On the pathophysiology, I need it from a credible source. My book that's required isn't a very good one at all, Surely disappointed.
Thanks!