I am writing a 7pg critical thinking paper but kinda worried my diagnosis arent on point...
My patient, 81 yr old male, came in the hospital with complaint of difficulty breathing with rapid, shallow breaths. His admittance diagnosis was hypoxia, respiratory distress caused by aspiration pneumonia. He has a history of CAD, HTN, DM, gout, spinal cord infarction, CVA, oral candiasis.
*The guidelines of the paper requires us to pick a patient with an already existing complication/illness with a new stressor...so im using the patient history of CVA = causing dysphagia = causing aspiration pneumonia...not far fetched right?
Getting back to patient's assessment. Pulmonary: lung sounds decreased bilaterally, o2 sat 95% on 2L NC, productive cough for clear sputum, patient self suction with yankaver, respirations normal nonlabored. Neuro: minimal movement in R and L leg. GU: foley for neurogenic bladder draining amber urine. Diet: NPO high risk of aspiration.
VS: bp 138/68, T 98.6, HR 86, RR 16, Pain 6/10 chest
*Guidelines requires 4 nursing diagnosis
1. Ineffective airway clearance r/t excess tracheobronchial secretions
2. Impaired gas exchange r/t insufficient oxygenation as a result of inflammation
3. Risk for aspiration r/t impaired swallowing (this one is confusing me. My instructor told me this is a priority i guess to prevent further aspiration?)
4. Imbalanced nutrition r/t NPO status?
I believe that these four are the priority. Do i have them in the right order? Does it sound correct?
I also found out very late after i developed my priority list that the patient has sepsis! but I couldnt find a nursing diagnosis specifically for sepsis. I would think that would take the #1 spot? .. sepsis can lead to death but all of the other diagnosis can too...im thinking ABCs and airway would be #1 right?
As you can tell, there is a lot of doubting going on
Any input would be greatly appreciated!