Nursing care plan helpp

Daytonite, BSN, RN · Oct 18, 2009

i'm curious as to how you came up with the diagnosis of ineffective airway clearance. diagnosing is based upon symptoms that the patient has. i strongly suggest that before you go out and find another care plan book that you look at and read the very first pages of the one that you have. most care plan books explain in one way or another the nursing process and how it is used in care planning and diagnosing. the nursing process is the tool we use to determine patient problems and a nursing diagnosis is merely the name, or label, we attach to those patient problems. it is the process of determining and finding those patient problems that is so important--the critical thinking part. you will be expected to have begun to mastered it and know it by the time you take the nclex and will be tested over it when you take the nclex exam. for purposes of care planning the first 3 steps of the nursing process are crucial to the customizing of care:

assessment of the patient
determining the problems
planning the care

i went through the information about this patient that you posted very carefully. assessment involves a number of investigations of information about the patient before drawing any conclusions about their nursing problems. assessment consists of:

a health history (review of systems) - you supplied plenty of this information: exacerbation of copd, obesity, smokes, allergy to penicillin and a dvt score of 5 due to pulmonary embolism and post thrombotic syndrome
performing a physical exam - no physical exam information was given. with copd i would expect to find a respiratory assessment (lung sounds, breathing assessment). with a history of dvt a circulatory assessment should have been done.
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - none addressed
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - the major disease should be looked up and studied. the pathophysiology of the diseases is necessary to the construction of the nursing diagnostic statements, particularly the etiologies of the problems.
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - a low sodium diet is a treatment. why was this ordered? is there a fluid retention problem? what medications were ordered for this patient and why?

from assessment information we look for abnormal data that the patient has. it is this abnormal data that becomes the clues, or the signs and symptoms of what will become the nursing diagnoses. every nursing diagnosis has a set of signs and symptoms just as every medical diagnosis has signs and symptoms. we wouldn't expect a doctor to diagnose us without doing some preliminary investigation. we also wouldn't expect a car mechanic to diagnose a problem with our car without doing some kind of inspection first. it is the same with nursing diagnosis. there must be some inspection and assessment on our part first and then the clues must be assembled and sorted into the proper nursing diagnoses.

unfortunately, you haven't provided any of the clues so that i can help you here. so, you need to go back through the data that you did collect because i'm sure you must have done the work. it is important to consider it for the diagnosing of the patient's nursing problems which may or may not have to do with their copd which is a medical diagnosis, not necessarily a nursing problem.