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.

:)

[Baloney Amputation, BSN, LPN, RN]

.....the defecation is going to hit the ventilation!

Pardon me for being a hijacking nerd, but LOL! I'd never heard that before.

[Daytonite, BSN, RN]

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

You are wrong. You need to read a pathophysiology book that explans what ventilation perfusion imbalance and alveolar-capillary membrane changes are. You are ignoring the definition of the diagnosis. The alveoli are structures in the lung, not the trachea. The cause of the impaired gas exchange must be happening to the alveoli and your related factor must show that linkage. Saying there are excessive secretions in the trachea doesn't do it. Sorry. I think you need to dig deeper for the related factor.

[ivanh3]

You are wrong. You need to read a pathophysiology book.

“The primary function of the respiratory system is to remove CO2 and provide O2…For these functions to be carried out properly there must be adequate provision of fresh air for delivery of O2 and removal of CO2 (ventilation)” (Weinberger & Drazen, 2005). Now I believe that is called “exchange”, and I also believe that increased tracheal secretions (as in trached patient can't get O2 if trach is occluded with secretions i.e. Bad airway! Bad!) could most definitely interfere with “adequate provisions of fresh air”. Weinberger and Drazen (2005) go on to say that gas exchange needs ventilation, perfusion, and diffusion to be effective.

“The gas exchange function of the lungs depends on a system of open airways …”(Porth, 2005). Now that is straight out of my pathophysiology book. Coupled with finding it in a nursing text listed as the first nursing diagnosis in a chapter about trach suctioning, I am not sure what else I could provide for you. I feel like I have documented my response fairly well. If you disagree that is great, I would honestly like to know your reasoning. Simply saying "you are wrong, go get a pathophysiology book" seems kind of weak.

It is all there in the sentence: impaired gas exchange related (connected by reason of an established or discoverable relation, Merriam Webster) to increased tracheal secretions. It doesn’t say “impaired gas exchange is increased tracheal secretions”

I am not making this stuff up. As I have already pointed out, this is in a nursing text, and it makes sense.

Porth C. (2005). Disorders of ventilation and gas exchange. Pathophysiology: Concepts of altered health states (7th ed., p. 689). Philadelphia: Lippincott, Williams, & Wilkins.

Weinberger, S. & Drazen, J. (2005). Disturbances of respiratory gas exchange. In D.L Kasper, A. S. Fauci, D.L. Longo, E. Braunwald, S.L. Hauser, & J.L. Jameson (Eds.), Harrison's principles of internal medicine (16th ed., pp. 1501-1505). New York: McGraw-Hill.

[Lunah, MSN, RN]

How does Impaired Gas Exchange mean Ineffective Airway Clearance? The writing was quite distinct.

Yes, I realize that ... but in getting very familiar with Mosby's guide to nursing diagnosis lately, what he described sounded to me like what would fall under Ineffective Airway Clearance.

However, because I am merely a student, I'll bow outta this one, pronto.

[BBFRN, BSN, PhD]

For the record, I agree that increased tracheal secretions would usually warrant an "ineffective airway clearance" nsg dx. I don't want to prolong the argument, but that would be the clearest standard nsg dx for that problem. I wouldn't want the OP to chance it that the CE will accept it, and really, as a former clinical instructor myself, I would've dinged a student for that, too. And Lunah, I thought he meant to say that as well, so you weren't the only one.

But, I would like to get back on track with helping the OP with her questions. :) Let's not get sidetracked here.

I would not use pain in your care plan, unless it is made clear to you that the pt is having pain issues, either from the pt record, nurse's report, or if you need to change a weaker nsg dx to that, after the pt c/o's pain >3 during your PCS. Someone else here said, keep it simple and don't go trying to be too creative. That is great advice. Take your care plan from your areas of care given. I can't stress that enough. You'll find that your examiner will give you areas of care to cover that are pertinent to what is going on with the patient.

[BBFRN, BSN, PhD]

I also want to add that in contrast to what someone else said about using "risk for infection" with anyone who has an IV, you will fail the PCS, if the patient is receiving antibiotics, so be very sure when you check the MAR, that the pt is not on ABTs.

[Daytonite, BSN, RN]

ivanh3. . .you have misdiagnosed the situation. it requires the use of two diagnoses. one for the impaired gas exchange, but using a more specific etiology than increased tracheal secretions. the second for ineffective airway clearance with an etiology of excessive mucus with increased tracheal secretions as one of the defining characteristics.

[ivanh3]

For the record, I agree that increased tracheal secretions would usually warrant an "ineffective airway clearance" nsg dx. I don't want to prolong the argument, but that would be the clearest standard nsg dx for that problem. I wouldn't want the OP to chance it that the CE will accept it, and really, as a former clinical instructor myself, I would've dinged a student for that, too.

I hear you guys in the sense of what would be the optimal nursing dx. But don't forget that in the unique situaiton of the CPNE. I had to pick a dx before I actually saw the patient. I would absolutely pick ineffective airway clearance if the first piece of info that I had was increased tracheal secretions. That info did not come until I did my assessement.

So under the CPNE guidlines I tested under, I believe the student can change their nursing diagnoses after they see the patient, but we were advised against it because that could possibley mean a complete change of your game plan (interventions might change) and the CE would have to approve it (as I recall, its been a while). They don't stop the clock for that, so I opted to make my chosen nursing dx work.

I can appreciate that people have ideas about how to write a dx/careplan, but this has to apply to how the CPNE functions.

[BBFRN, BSN, PhD]

EC grad here. Class of '04.

[Firemedic7]

Ok, I have a Kardex that lists one my AOC's as "Resp. Mgmt. ISX10." Can I list ineffective airway clearance even though nothing else is listed about any airway problems?

[Lunah, MSN, RN]

I did IS x 6-10 reps for my last patient, and it was because she'd had surgery on her fractured hip; her lungs weren't great, but she was 90. I probably could have gotten away with using that dx on her, but the doc's notes said her lungs were clear, so I went in with acute pain and risk for injury instead. But yeah, one good thing to check in the chart during planning is to see if they've had abnormal lung sounds, then go from there. You're definitely thinking about this the right way! Your interventions could be "IS x 10" and "assess lung sounds." I imagine your goal could be something about the patient having clear lung sounds. (Remember, for EC's purposes, lung sounds are either clear or abnormal -- nothing in between.)

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

In my CPNE I was given the areas of care (AOC) of respiratory assessment and oxygen management for a pneumonia patient.

Don't mean to butt in...but what about using "Activity Intolerance?" If the patient has pneumonia and has been on bedrest, s/he will probably get weak and/or short of breath on exertion. Your interventions could be 1) Assess the patient's tolerance to activity (as this is a critical element of Oxygen Management) and intervention 2 could be what ever you are assigned under mobility, since that is a required area of care also. (transfer, assist with ambulation) This way you are not making extra work for yourself. If the goal is not met, an alternative intervention could be to provide more frequent rest periods. Just trying to be helpful. :nuke: