Nursing DX Question Cont..

grantz · Oct 29, 2011

If you have a patient with Pneumonia...can you have 2 nursing diagnoses pertaining to the airway?
Ineffective Airway Clearance related to retained secretions as evidenced by ineffective cough, difficulty breathing, and respiration rate of 24/minute
Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by O2 sat = 91% on RA.
Am I setting myself up for difficulty by using two diagnoses that are "close" to each other?

I'd go for the first one. It is better that way just my one cent :)

xtxrn, ASN, RN · Oct 29, 2011

I think they're different enough- although I'd keep the respiratory rate with the impaired gas exchange (the body is triggered to breathe by changes in CO2 levels... if the CO2 level rises, the brain triggers respirations).

The clearance r/t retained secretions makes sense w/ineffective cough and difficulty breathing.

If the primary diagnosis is pneumonia, I'd want to see both :)

windmill182 · Oct 29, 2011

Can you do clearance r/t retained secretions w/ inneffectice cough and difficulty breathing when the assessment just says, "coughing without sputum. Xray shows interstitial infiltrates and Dyspnea. Resp at 24."

No mention of lung sounds. I guess I am assuming that because its an infection and there are interstitial infiltrates that there is fluid/sputum present and he isnt effectively coughing it up. You would want them to cough up sputum with an infection wouldn't you?

xtxrn, ASN, RN · Oct 29, 2011

Interstitial pneumonia doesn't necessarily have gunk in the airways, since the infiltrates are in the lung tissue..... look up interstitial pneumonia (it's not always covered like bronchial pneumonia/lobar pneumonia- please excuse my dull vocabulary; not feeling that great :)).

There may not be sputum :) If there were, yes- you'd want them to get rid of it with effective coughing.

The definition of interstitial pneumonia will give you more info re: coughing. I'll check back :up:

nurseprnRN, BSN, RN · Oct 31, 2011

"

ineffective airway clearance related to retained secretions as evidenced by ineffective cough, difficulty breathing, and respiration rate of 24/minute

impaired gas exchange related to alveolar-capillary membrane changes as evidenced by o2 sat = 91% on ra.

am i setting myself up for difficulty by using two diagnoses that are "close" to each other?"

i am not sure where this concern about having two nursing diagnoses that are "close" to each other (whatever that means) comes from. i'm suddenly seeing it a lot here. is it leftover from early childhood, where you don't want to eat (or even look at) two perfectly good vegetables touching each other on the plate? (that's a joke, kid.)

seriously, there's a difference between two nursing diagnoses that are basically the same thing and two nsg dx involving the same body system.

ineffective airway clearance is a mechanical thing-- there's a weak cough, or an obstruction from tumor or thick secretions, or bronchiectasis (look it up), or weak inspiratory/expiratory effort, or the like. you would assess for ventilatory competence-- how many words can s/he say in a sentence before having to take a breath, listen to breath sounds to see how much lung is being used in each breath, if you have pulmonary function testing results to evaluate, or an incentive spirometer to use bedside, chest xray report for areas of consolidation, that sort of thing. you'd listen for rhonchi (please spell this correctly), which are snoring or honking sorts of sounds in the bronchi (not alveolar), and see if they clear with a productive cough (or is s/he not able to do this?).

impaired gas exchange is at the alveolar capillary level, and is a totally different thing. for that you have to look at blood gases (in a pinch you can look at spo2, but you can have a decent/"normal" spo2 and an elevated or decreased paco2, indicating abnormal gas exchange. a low spo2 is impaired gas exchange fer sher, absent some rare zebras). or you may have to extrapolate from what you know about the effects of impaired alveolar exchange, from congestive heart failure or pneumonia, say. you would assess for alveolar sounds (rales, pronounced "rahhlz", little crackling sounds like what you hear when you rub some hairs between your fingertips near your ears). color is big-- circumoral (around the mouth) cyanosis or blue nailbeds; those funny-looking fingertips (clubbing) you see in chronic hypoxia, chronically high crit you see in chronic hypoxia; a diagnosis of copd or chf, both of which give you bad gas exchange (for different reasons: copd, because there's less pulmonary capillary bed to use for it due to alveolar destruction, and chf, because the alveoli are full of fluid, making it hard to do gas exchange there).

so yes, you can absolutely have two things wrong with you, and these are the very nursing dx you would want to make if you found that your patient demonstrated the exam findings to support them.