Help with Nursing Diagnosis

  1. I am working on a Care Plan for school and I cannot come up with Nursing Diagnosis for a pt with bilateral pleural effusions. Any suggestions?
  2. Visit MeAndrawl profile page

    About MeAndrawl

    Joined: Feb '07; Posts: 4


  3. by   nicuRN2007
    I'd say impaired gas exchange.
  4. by   GingerSue
    related to collection of excess fluid in the intrapleural space with compression of overlying lung tissue
    (depending on which one: empyemic, hemothorax, exudative, transudative, or chylothorax)

    any infection?
    any pain?
    any anxiety?
    Last edit by GingerSue on Mar 21, '07 : Reason: excess fluid
  5. by   MeAndrawl
    No pain, infection or anxiety. It is a transudative effusion. The problem is that I need about 3 Nursing diagnoses. Thanks for the suggestions.
  6. by   sirI
    Hello, Meandrawl,

    I moved your thread to the Nursing Student Assistance forum where you will receive more responses. is the best place to come for assistance.
  7. by   nicuRN2007
    Well, I'd definitely say impaired gas exchange related to accumulation of excess fluid in the pleural space.

    Is the patient SOB, tachypnic, coughing, or using accessory muscles? If so, Ineffective breathing pattern related to decreased lung compliance may be an option.

    Patients with impaired gas exchange are often anxious, so anxiety could be an option.

    (Risk for) Activity intolerance?
    Deficient knowledge?
    Risk for infection (does patient have IV's. Foley Cath)?

  8. by   nicuRN2007
    Are the transudative effusions a result of congestive heart failure?

    If so you might could use decreased cardiac output or excess fluid volume.
  9. by   Daytonite
    Like medical diagnoses, the determination of nursing diagnoses is based upon the symptoms that the patient is having. So, what are your patient's symptoms? In general, a patient with pleural effusions will have:
    • dyspnea
    • pleuritic chest pain
    • fever
    • fatigue
    From that you can probably use one or some of these nursing diagnoses:
    • Ineffective Breathing Pattern
    • Ineffective Airway Clearance
    • Impaired Gas Exchange
    • Hyperthermia
    • Acute Pain
    • Fatigue
    It is important that you understand that nursing diagnoses, like medical diagnoses, also have signs and symptoms associated with each of them. If you have a care plan or nursing diagnosis book you will see that the symptoms of dyspnea is included as a symptoms of Ineffective Breathing Pattern, Ineffective Airway Clearance and Impaired Gas Exchange. You must also look at other symptoms your patient had as well that will fit with one or more of these diagnoses in order to make a proper diagnosis assignment.
  10. by   pycho24
    I am working on a case study for school does anyone know where to find five priority nursing diagnosis for fever possible sepsis. I would greatly appreciate it.
  11. by   Daytonite
    Quote from pycho24
    i am working on a case study for school does anyone know where to find five priority nursing diagnosis for fever possible sepsis. i would greatly appreciate it.
    there is a specific sequence of events you need to follow to arrive at a nursing diagnosis. it involves using the nursing process and following these steps in the sequence that they occur:
    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)
      • a physical assessment of the patient
      • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
      • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
      • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
      • medical disease information/treatment/procedures/test reference websites
    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)
      • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
      • your instructors might have given it to you.
      • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95
      • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
      • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
      • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
    3. planning (write measurable goals/outcomes and nursing interventions)
      • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
        • improve the problem or remedy/cure it
        • stabilize it
        • support its deterioration
      • interventions are of four types
        • assess/monitor/evaluate/observe (to evaluate the patient's condition)
          • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
        • care/perform/provide/assist (performing actual patient care)
        • teach/educate/instruct/supervise (educating patient or caregiver)
        • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    there is also help on this sticky thread:
    Last edit by Daytonite on Sep 22, '08