Need Help with my Nursing DX

[JdNNurse2B]

I am having trouble wording a Nursing DX for a patient that I had. Elderly woman in for pneumonia, cdiff, Acute Renal Failure. On A/C ventilation. I have to address her airway.

Altered Breathing patterns r/t ???????

My prof was like "isn't her airway compromised"? well it is. but there is now "compromised airway" in the NANDA diagnoses.

Thanks in advance.

[Daytonite, BSN, RN]

the r/t part, or related to part, of the nursing diagnostic statement very specifically has to do with the etiology, or cause, of the nursing problem. for a breathing problem which is a physiological function this generally has to do with the underlying pathophysiology of what is going on in the person's body--in this case the pneumonia which is an infection of the lungs. the choice of any diagnosis, however, is dependent on the symptoms the patient is having.

your nursing professor is suggesting a compromised airway. the first thing i would ask myself is what does "compromised" mean? i want to illustrate something for you so, i pulled out my webster's new world dictionary of the american language, college edition, the world publishing company, 1966 which i've had since i started college in 1967 and here's what it says on page 300: "to lay open to danger, suspicion, or disrepute; endanger the interests of." kind of vague, but it does tell me something that i know very well about care planning. that is, nursing problems are based upon abnormal conditions. so, what your instructor was doing was giving you a big hint to look at what was going on with your patient's airway. things in the airway are compromised there (abnormal, in danger, suspicious). without telling you directly, she wanted you to figure out that the answer was in reviewing your assessment data of the patients respiratory system. (well, also knowing where to find nanda taxonomy information as well.)

did you look up the symptoms of pneumonia? (low grade fever, productive cough, an ill appearing patient, dyspnea [or short of breath], tachypnea, tachycardia, rales [or rhonchi], diminished breath sounds, bronchial breath sounds, dullness to percussion, tactile fremitus, and egophony) did your patient have any of these symptoms? how about any productive cough, dyspnea, rales, diminished breath sounds, or bronchial breath sounds?

all care planning begins with assessing the patient and making a list of their symptoms. it is from those symptoms that a diagnosis is chosen. all nursing diagnoses have a defined set of symptoms that nanda calls defining characteristics.

there are three possible nanda diagnoses that pertain to "compromised airways" and in each case what makes the choice of using any is the patient's symptoms that you obtained when assessing them and whether or not the patient matches a description of the nursing problem. i've linked you into online information about these diagnoses and copied the nanda taxonomy information from them as well so i could highlight a few things. keep in mind that a nursing diagnosis is only the shorthand wording for the problem. the description of the true nursing problem is actually in the definition of the diagnosis. the related factors are the underlying causes of why the problem is occurring. you decide what this is for your patient based on what you know about their background information and medical diagnosis (in this case the pneumonia and knowledge about its pathophysiology). the underlined blue titles in parentheses are weblinks to nursing diagnosis pages on the internet from the companion care plan constructor websites for betty j. ackley and gail b. ladwig's nursing diagnosis handbook: a guide to planning care and meg gulanick and judith l. myers' nursing care plans: nursing diagnosis and intervention books.

1. ineffective airway clearance ([color=#3366ff]ineffective airway clearance) and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=02
   • definition: inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
     
   • symptoms: (can include one or more of the following) dyspnea; diminished breath sounds; orthopnea; adventitious breath sounds (rales, crackles, rhonchi, wheezes); cough, ineffective or absent; sputum production; cyanosis; difficulty vocalizing; wide-eyed; changes in respiratory rate and rhythm; restlessness
     
   • related factors: for an obstructed airway: airway spasm, retained secretions, excessive mucus, presence of artificial airway, foreign body in airway, secretions in bronchi, exudate in alveoli; for physiological problems: neuromuscular dysfunction, hyperplasia of bronchial walls, copd, infection, asthma, allergic airways [note: pneumonia is an infection]
     
     • one suggestion would be: ineffective airway clearance r/t lung infection, excessive and retained secretions aeb
     
     

     [*]ineffective breathing pattern ([color=#3366ff]ineffective breathing pattern) and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=08

     • definition: inspiration and/or expiration that does not provide adequate ventilation
       
     • symptoms: decreased inspiratory/expiratory pressure; decreased minute ventilation; use of accessory muscles to breathe; nasal flaring; dyspnea; altered chest excursion; shortness of breath; assumption of a three-point position; pursed-lip breathing; prolonged expiration phases; increased anteroposterior diameter; respiratory rate/min: infants = 60, ages 1-4 = 30, ages 5-14 = 25, adults over 14 = 24; depth of breathing: adult tidal volume = 500 ml at rest, infant tidal volume = 6-8 ml/kg; timing ratio; decreased vital capacity
       
     • related factors: hyperventilation, hypoventilation syndrome, bony deformity, pain, chest wall deformity, anxiety, decreased energy/fatigue, neuromuscular dysfunction, musculoskeletal impairment, perception/cognitive impairment, obesity, spinal cord injury, body position, neurological immaturity, respiratory muscle fatigue
       • one suggestion would be: ineffective breathing pattern r/t respiratory muscle fatigue aeb

         [*]impaired gas exchange ([color=#3366ff]impaired gas exchange) and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=23

         • definition: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
           
         • symptoms: visual disturbances; decreased carbon dioxide; dyspnea; abnormal arterial blood gas levels; hypoxia; irritability; somnolence; restlessness; hypercapnia; tachycardia; cyanosis; abnormal skin color (pale, dusky); hypoxemia; hypercarbia; headache on awakening; abnormal rate, rhythm, depth of breathing; diaphoresis; abnormal arterial ph; nasal flaring
           
         • related factors: ventilation-perfusion imbalance; alveolar-capillary membrane changes (an explanation of these two things is on post #5 of this thread: https://allnurses.com/forums/f50/asthma-impaired-gas-exchange-302401.html)
           
           • one suggestion would be: impaired gas exchange r/t ventilation-perfusion imbalance aeb

             fyi and for future diagnosing, there is current nanda diagnoses and taxonomy information listed in the index of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary. hope this has helped you. good luck with writing the remainder of this care plan.

             
             

           [*]note: this diagnosis does not particularly address a compromised airway. read the definition carefully. it has to do with the pathology going on in the alveoli of the lungs. in other words, oxygen and carbon dioxide are not passing into and out of the blood in the lungs themselves like it is supposed to. this has nothing to do with what is going on in the bronchi or trachea. i listed it here because the inflammatory process of pneumonia causes a build up of pus and secretions in the alveoli that results in gas exchange problems for these patients (ventilation-perfusion imbalances). it would be appropriate to include this diagnosis along with one or both of the two above if your patient has the appropriate symptoms of it.