Nursing DX - Respiratory, Help!

[Qtip]

I'm writing a care plan and I need some help nailing down the best Nursing dx. I don't know whether to go with Ineffective Airway Clearance or Impaired Gas exchange.

My patient has a almost constant productive wet cough with clear secretions, 92% 02 sat on Room air(02 is ordered), c/o SOB and difficulty breathing, and posterior crackles and wheezing.

The secretions are clear making it difficult for me to write up Impaired gas exchange and the accompanying rationale since I can't really say it's an infection in the alveoli which would give my related to as ventilation perfusion.

Then with ineffective airway clearance, my question relates to the fact the patients cough is productive and constant, would this NDx still be correct? I'm confused as I thought ineffective airway clearance is for a non productive or absent cough?

Any help is appreciated, thanks.

[NCRNMDM, ASN, RN]

I would think more along the lines of ineffective breathing pattern. Sure, his sat is 92 percent, but that isn't great, and he is also having shortness of breath and difficulty breathing, and he has adventitious breath sounds. I don't think he has ineffective airway clearance since he is coughing and the cough is productive. Impaired gas exchange can't really be evaluated unless you have an ABG to go along with his oxygen saturation. What is his respiration rate? Is he struggling to breath? These are things you need to know in order to evaluate what his respiratory status really is. If he is complaining of shortness of breath and difficulty breathing, has adventitious breath sounds, and is struggling at all to breathe, then I would go with ineffective breathing pattern.

[Esme12, ASN, BSN, RN]

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

http://www.snjourney.com/clinicalinfo/careplans/careplann.htm

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.pterrywave.com/nursing/care%20plans/14.aspx

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

how does a doctor diagnose? he/she does (hopefully) a thorough medical history and physical examination first. surprise! we do that too! it's part of step #1 of the nursing process. only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. each medical diagnosis has a defined list of symptoms that the patient's illness must match. another surprise! we do that too! we call it "critical thinking and it's part of step #2 of the nursing process. the nanda taxonomy lists the symptoms that go with each nursing diagnosis.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories.

https://allnurses.com/general-nursing-student/help-care-plans-286986.html