Need help with nursing diagnoses

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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.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

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.

we can't use medical diagnoses as the related factors in a diagnostic statement. it's not the pneumonia causing the pain. pain is r/t

  • inflammatory response causing pressure on pleural nerve endings

  • or, sore intercostal muscles (
    from all the coughing
    )

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Thank you for your help! :)

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I would add Imparied gas exchange r/t pneumonia

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Specializes in med/surg, telemetry, IV therapy, mgmt.
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:

  • alveolar-capillary membrane changes - the membrane, or tissue, that separates the wall of the air sac (alveoli) and the capillary (vessel) walls has changed from it's normal anatomical structure and has become permanently abnormal, or pathological, because there was or still is chronic disease present
  • ventilation perfusion imbalance - either more oxygen or more carbon dioxide is being exchanged than is normally supposed to occur because of some sort of temporary blockage at the level of the alveoli.

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:

  • impaired gas exchange r/t alveolar-capillary membrane changes
  • and you can also get away with this very careful wording: impaired gas exchange r/t alveolar-capillary membrane changes secondary to copd and pneumonia

these ways explain the etiology of the gas exchange problem.

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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:

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Specializes in med/surg, telemetry, IV therapy, mgmt.
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

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:

  • chronic obstructive asthma
  • chronic obstructive bronchitis
  • emphysema
  • chronic bronchitis with emphysema

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.

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?

i explained the use of
impaired gas exchange
in my post #4 above. please read it again.

there are only two related factors that can be used with this diagnosis:
alveolar-capillary membrane changes
and
ventilation perfusion imbalance
. someone with copd has
alveolar-capillary membrane changes
(the membrane, or tissue, that separates the wall of the air sac (alveoli) and the capillary (vessel) walls has changed from it's normal anatomical structure and has become
permanently
abnormal, or pathological, because there was or still is chronic disease present). i also explained this on this previous thread:
https://allnurses.com/forums/f50/asthma-impaired-gas-exchange-302401.html
. it is the reason why you always need to read about the pathophysiology, signs and symptoms and complications of the patient's medical diseases before delving into their nursing diagnoses.

the information that follows the
aeb
part of the diagnostic statement must be the symptoms (evidence) you have that proves the
impaired gas exchange
.

a 3-part diagnostic statement is constructed this way:
p (problem, the nursing diagnosis) - e (etiology, what is causing the problem) - s (symptoms of the problem)

your abnormal abg is a ph of 7.48, and pco2 of 29. the hco3 measurement is not given. po2 is not a significant factor in the analysis of abgs. with a ph of 7.48 this patient is in alkalosis. since the pco2 is abnormal, this is significant and indicates that the patient is in
respiratory alkalosis
.

your diagnostic statement can/should be written as
impaired gas exchange r/t alveolar-capillary membrane changes secondary to copd aeb abnormal abgs with ph of 7.48 and a pco2 of 29
.

"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!

the doctor specifically documented that this patient has chf. it is not surprising to have this along with copd. look up its pathophysiology, signs and symptoms and complications. cad, htn, and carotid stenosis are linked and related. once someone has cad the progression of cad moves forward and never reverses itself. htn is expected. chf is a complication and expected as well. the angina he had was due to oxygen deprivation that his heart cells experienced. when the heart cells themselves do not get enough oxygen angina pain results. supplemental o2 helps. it is unfortunate that you do not have a heart rate because his potassium of 5.6 is high and elevated potassium rates often correlate with slowed heart rates. the patient's edema, while you believe it to be a problem of peripheral circulation, is more likely a problem of the chf and the heart failure as are the crackles in the lungs. a lot happens with chf and many of this patient's symptoms are because of the chf.

i would formulate this diagnosis:
decreased cardiac output r/t altered contractility secondary to chf aeb fine crackles in lungs.
[you said your instructor only wants you to use one symptom after the aeb, right?]

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.

lack of adequate fluid intake
is a symptom of this diagnosis. this diagnosis is actually referring to dehydration. the deficit occurs because
fluid becomes lost
. inadequate intake merely means that the lost fluid isn't getting replaced. so, your related factor always has to indicate how the fluids are getting lost. is the patient on diuretics?

i thought you could only use one aeb symptom.

the correct nanda diagnosis of
deficient fluid volume r/t impaired excretion of sodium and water aeb poor skin turgor, dry skin.

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Thanks Daytonite!:yeah:

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.!

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Specializes in med/surg, telemetry, IV therapy, mgmt.
thanks daytonite!:yeah:

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/

  1. impaired gas exchange r/t alveolar-capillary membrane changes secondary to copd aeb abnormal abgs with ph of 7.48, a pco2 of 29 and hco3 of 21.9.
  2. decreased cardiac output r/t altered contractility secondary to chf aeb fine crackles in lungs.
  3. deficient fluid volume r/t impaired excretion of sodium and water aeb poor skin turgor, dry skin, elevated serum potassium and bun and patient's statement that " i am not drinking water often enough."

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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!:confused:

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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!

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