I need to make a care plan but with so many dx she has on hx, I have no idea which one to work on. I NEED HELP!! IT'S MY FIRST CAREPLAN ON A REAL PT IN ICU!
Chief complaint: acute on chronic respiratory failure, metastatic ovarian cancer to lungs with malignant pleural effusion, respiratory distress, and [supposedly PNA as per the RN that I was following told me but PNA is not on the chart]
i have been juggling my primary dx between acute resp. failure and pleural effusion but I've done research that pleural effusion is only secondary to a disease, so I'm not sure if I can use this:
Malignant R pleural effusion secondary to lung cancer AMB rapid respirations of 22-25/min and dyspea.
The pt is Awake and alert to person but uses inappropriate words and always screaming when she wants her sister.
I don't know how to chart subjective findings when she couldn't really verbalize anything but screaming.
JustBeachyNurse, LPN
13,957 Posts
It's AEB as evidenced by not AMB (I'm guessing you are saying as manifested by?).
Your r/t and AEB MUST match the NANDA-I defining characteristics and related factors.