Here is the scenario;
A 60 yr. old caucasian is admitted for complaints of dyspnea on exertion and retention of fluids.
Patient has history of CHF w/ arrhythmia, A. Fib, Coronary artery disease, Type I diabetes with an insulin pump, COPD, hypertension, vascular disease, and chronic renal disease. Client had a transmetatarsal amputation of his left toes 3 years ago.
Assessment: Client speech is clear, alert and oriented x 3. PERRLA.
Calm, cooperative, communicates verbally
Symmetry of movement.
Reported pain felt on upper chest during exertion to breathe.
Rated pain at 7 (1-10 scale). EHOB, 1 hour latter pain client
rates pain at 5 (1-10 scale). Complaints of chronic fatigue
BP 135/97, HR 108, AP 108 1+ pitting edema on buttocks and
posterior thigh. Pulses equal and palpable bilaterally.
Neck veins flat, Homan's sign negative, capillary refill <3 secs
skin: no color changes, warm and dry
Client uses abdominal and neck muscles to breath.
Chest symmetrical when breathing
Incentive spirometry <500 ml volume
non-productive dry cough
Crackles auscultated in lung bases
Nasal cannula at 2 L/min oxygen
Abdomen nontender active bowel sounds on all
transmetatarsal left foot closed wound, pink, dry,
with numerous dead skin. dressing is dry and intact
Client uses assistive devices for ambulation
Client needs assistance with ADLS
Priority nursing diagnosis:
1. Ineffective breathing patern r/t decreased energy/ fatigue
aeb dyspnea, use of accessory muscles to breath, depth of
breathing <500 ml. volume.
2. Excess fluid volume r/t compromised regulatory mechanism
aeb dyspnea, 1+ pitting edema.
I would appreciate any feedback.
Mar 22, '07
I would add dyspnea to the "aeb" items on your diagnosis of Ineffective Breathing Pattern since it is documented in the chart as one of his symptoms even though the doctor is the one mentioning it. It's still a data assessment item.
Are you including any more nursing diagnoses? You have other symptoms that can be used with other nursing diagnoses. I was thinking of Ineffective Airway Clearance as well since the patient has a non-productive dry cough and crackles as well as COPD and the dyspnea. With CHF, coronary artery disease and hypertension and having the edema I would use Decreased Cardiac Output rather than the Excess Fluid Volume. The reason is because the CHF is most likely the underlying cause of the edema and the hypertension. Excess Fluid Volume is only partially getting to the underlying problem.
Insofar as prioritizing the nursing diagnoses that you have listed, you have them prioritized correctly by Maslow's Hierarchy of Needs. Airway and Circulation diagnoses always get sequenced first. Fluid volume falls more toward the nutritional aspects of physiology needs and is correctly sequenced after oxygen needs. If you decided to include Decreased Cardiac Output it would be sequenced after the airway and breathing diagnoses, but before the fluid volume ones.