Nsg Diagnosis in CPNE study guide

[shawnnarae]

I am going through the study guide doing all the practice questions and sample PCS things they have in there and all its doing is making me feel stupid. I think I may be lost on this nursing diagnosis stuff. I always end up thinking of a different one and not the one excelsior thinks is the best... or whatever. Anyway, I am just really frustrated and needed to get it out before I freak out.

:)

[Medic2RN, BSN, RN, EMT-P]

To the OP:

Prior to taking the CPNE, I spent a lot of time making up careplans and sending them to the instructors for review. I would make up patient scenerios, design a careplan for them, then send it to EC. I always received wonderful feedback and advice.

I did this until I no longer received any criticism regarding my careplans. I highly recommend that you utilize that service, it was extremely helpful in shaking one more of those pre CPNE monkeys off of my back.

Good luck!!

[Firemedic7]

This has been helpful for me-

I just want to make sure I am understanding. Can you use an assessment as an intervention? e.g. in risk for infection "will assess wound for redness and unusual drainage"? Or for ineffective airway "will assess for abnormal lung sounds"?

Any help appreciated

[shawnnarae]

Ooo, they actually let you send them care plans?? Who do I send these to?

[Daytonite, BSN, RN]

i'm not sure about the rest of you guys, but the "nursing diagnosis" is what has confused me throughout my ec studies.

pounding into my head a nursing diagnosis is not a real diagnosis. it is not a true diagnosis, but is constantly called diagnosis.. very confusing for me to get my brain around.

if you read the dictionary definition of "diagnosis" you will find that it says. . .the resulting decision or opinion after the process of examination or investigation of the facts. look up diagnosis in the thesaurus as well. that is exactly what any medical diagnosis, nursing diagnosis or a diagnosis of what is wrong with your car made by a mechanic is. it follows the steps of problem solving. for nursing, specifically, it follows the assessment step of the nursing process which must be done first, then the abnormal data evaluated, examined and a decision made as to what the nursing problem(s) is(are) that the patient is having. if you think a "real" or "true" diagnosis is a medical diagnosis, then it is time to broader your horizons. even plumbers make plumbing diagnoses.

nanda has helped nurses with nursing diagnosis in that it has developed a taxonomy of the diagnoses which is an arrangement or ordering of the nursing diagnoses that includes descriptions of each, symptoms (nanda calls them defining characteristics), and related factors (etiologies). using a nursing diagnosis reference to help in picking and composing nursing diagnoses should be done as commonly as using a dictionary to check word usage and spelling until you are familiar with the signs/symptoms and etiologies of the nursing diagnoses you use the most. this is no different from the way practiced by any doctor of a specialty area of medicine, or a car mechanic, or a plumber, all of which who know their stuff when it comes to determining (diagnosing) problems in their area of expertise.

[Daytonite, BSN, RN]

can you use an assessment as an intervention? e.g. in risk for infection "will assess wound for redness and unusual drainage"? or for ineffective airway "will assess for abnormal lung sounds"?

there are four types of nursing interventions (actions) that include the following:

1. assess/monitor/evaluate/observe (to evaluate the patient's condition)
   
2. care/perform/provide/assist (performing actual patient care)
   
3. teach/educate/instruct/supervise (educating patient or caregiver)
   
4. manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
   

an assessment can be a type of intervention, but only to evaluate what you already know and assess for changes. nothing replaces that initial baseline assessment done as the first step pf the nursing process. an intervention is always done to treat or intervene with a defining characteristic (or symptom, response) that a patient has as a result of their health related condition that came about as a result of their nursing problem.

[FocusRN]

This has been helpful for me-

I just want to make sure I am understanding. Can you use an assessment as an intervention? e.g. in risk for infection "will assess wound for redness and unusual drainage"? Or for ineffective airway "will assess for abnormal lung sounds"?

Any help appreciated

For the CPNE I believe, that only one of your interventions can be an assessment.

[Lunah, MSN, RN]

For the CPNE I believe, that only one of your interventions can be an assessment.

That is correct! :) They don't want you to use an assessment for both.

[ivanh3]

This has been helpful for me-

I just want to make sure I am understanding. Can you use an assessment as an intervention? e.g. in risk for infection "will assess wound for redness and unusual drainage"? Or for ineffective airway "will assess for abnormal lung sounds"?

Any help appreciated

The answer is yes you can. In my CPNE I was given the areas of care (AOC) of respiratory assessment and oxygen management for a pneumonia patient. One of the components of respiratory assessment is to listen to lungs sounds. I used "I will assess lung sounds" as one of my interventions.

My nursing dx looked like this: Impaired gas exchange r/t increased tracheal secretions AEB visible secretions at trach site. I will 1) assess lung sounds and 2) maintain oxygen flow (the second intervention was a component of oxygen management)

Now this is very important. It seems like I should have put "I will suction patient", but under the 11th edition of the CPNE guide that intervention was under respiratory management, not assessment. Had I suctioned, I would have been doing something that I was not assigned, and it could have gotten me failed. I didn't worry about the suctioning because the family had already been trained and had been suctioning him during my PCS.

I don't remember if there is a limit on assessment interventions or not. I do remember there being a limit on "risk for" nursing dx's.

[Daytonite, BSN, RN]

my nursing dx looked like this: impaired gas exchange r/t increased tracheal secretions aeb visible secretions at trach site. i will 1) assess lung sounds and 2) maintain oxygen flow (the second intervention was a component of oxygen management

if you had turned this in to me i would have dinged it and deducted points. it is an incorrectly determined and constructed diagnosis. tracheal secretions are never a related factor for this diagnosis. if you read the definition of impaired gas exchange you will see that it specifically says excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane (pg. 94, nanda-i nursing diagnoses: definitions & classification 2007-2008). that means the problem is meant to be dealing with situations occurring in the alveoli of the lung. recall from anatomy that the alveoli are the terminal elastic, thin-walled air sacs of the lungs surrounded by tiny capillaries which is where carbon dioxide and oxygen are actually exchanged during respiration. if you look further at the nanda information for this diagnosis you will find that there are only two related factors, or causes, for this situation to occur. a ventilation perfusion imbalance, which is what your related factor should be when you have secretions blocking the gas exchange in the alveoli, is an imbalance between oxygen and carbon dioxide exchange that exists when there is either more oxygen or more carbon dioxide being exchanged than is normally supposed to occur. the usual reason for this is some sort of blockage at the level of the alveoli. do not make the mistake of diagnosing a blockage in the bronchioles or trachea as being responsible for impaired gas exchange because oxygen and carbon dioxide are not exchanged in the blood vessels of the bronchi. ventilation perfusion imbalances occur when the alveoli are clogged with debris, exudates or built up sputum as in pneumonia, congestive heart failure or atelectasis following surgery.

[Lunah, MSN, RN]

I think he probably meant "Ineffective airway clearance" for that one ...

[Daytonite, BSN, RN]

I think he probably meant "Ineffective airway clearance" for that one ...

How does Impaired Gas Exchange mean Ineffective Airway Clearance? The writing was quite distinct. The definitions and meanings of the two are very distinct. If a medical student diagnoses pneumonia, but means bronchitis, the defecation is going to hit the ventilation! Why should nursing students get it any easier for not learning this. We only have 188 diagnoses--and there are only about 70 or so that are used most commonly.

[ivanh3]

If you had turned this in to me I would have dinged it and deducted points. It is an incorrectly determined and constructed diagnosis. Tracheal secretions are never a related factor for this diagnosis.

With all due respect, I do not agree. Impaired gas exchange can be caused by anything that interferes with the process of diffusion (“Nursing Diagnosis”, 2007). These causes can be numerous. Certainly, as you pointed out, damage/obstruction to the alveoli themselves could affect this process by either blocking the exchange or allowing “too much” exchange. However, hypoventilation can most definitely impair gas exchange (“Nursing Diagnosis”). How? Because as ventilation decreases there is a build up of one substance (in this case CO2) that decreases (impairs) the ability of that same substance on the other side of the membrane to cross over. In other words if CO2 on the lung side of the membrane is high, CO2 from the vascular side has to work harder and harder to cross the membrane because of the increasing concentration on the lung side. In diffusion which is a passive process the gases always move from areas of higher concentration to areas of lower concentration.

This is also true from a blood flow standpoint. You can have impaired gas exchange due to a decrease in blood flow from either a clot or cardiac output problem (“Nursing Diagnosis”, 2007). Here again, the problem is not with the alveoli itself but the gas concentrations being altered by the decrease in blood flow. So like hypoventilation due to upper airway obstruction (due to increased tracheal secretions) we have an issue (impaired gas exchange) that stems from a problem in a different location of the body.

Increased tracheal secretions (or upper airway obstructions in general) can cause a decrease in ventilation as can narcotics, anesthesia, and sleep apnea (Beers et al., 2006). None of these directly involve the alveoli walls (in the short term) yet interfere with or impair the ability of proper gas exchange. Sue Roe in her text Delmar’s Clinical Nursing Skills & Concepts (2002) gives “impaired gas exchange related to increased tracheal secretions” as her first nursing diagnosis in the section discussing tracheal suctioning.

So for the record, I am familiar with the NANDA definition. However, I am not ignoring that gas exchange issues can have other etiologies than diseased/damaged alveoli.

Also for the record, I did not mean "ineffective airway clearance" and yes I know that "impaired gas exchange" does not mean "ineffective airway clearance", but guess what..."ineffective air way clearance" can sure lead to hypoventilation and therefore to "impaired gas exchange".

Thanks,

Ivan

Beers, M., Porter, R., Jones, T., Kaplan, J., & Berkwits, M. (eds.). (2006). Ventilatory failure. Retrieved June 10, 2008 from http://www.merck.com/mmpe/sec06/ch065/ch065d.html#CIHHHIIE

Nursing diagnosis: Impaired gas exchange. (2007). Retrieved June 10, 2008 from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=23

Roe, S. (2002). Suctioning tracheal tubes. Delmar’s clinical nursing skills & clinical concepts (1st ed., pp 462-463). Delmar