Which nursing Dx would you choose?

  1. I'm working on a concept map and not sure which NDx applies to the situation. The pt has exacerbated COPD, DNR, WBC 19000, left shift w/neutros, hemoglobin 10, BUN 25, pH 7.493, paCo2 31 (BTW, is he in resp alkalosis or are there other determining factors to examine?). His activity should be OOB 3xs/day. Before he was admitted he was walking around his home. He also does not normally use a mobility device. He does not want to get out of bed, nor does he want to change positions. So, is this Activity Intolerance, Impaired physical Mobility, Disuse Syndrome? Or something else? Any input would be appreciated. He is my first pt, so my assessment seems incomplete... it was difficult to know which details were pertinent.

    Other Nurs Dx I am working on for this client: Impaired Gas Exchange, Chronic Pain, Risk For Infection (so obviously activity is not #1)
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  3. by   augigi
    I'm not an expert at NANDA careplans, but I'd go with Activity tolerance r/t exacerbation of COPD, as evidenced by shortness of breath, respiratory alkalosis.

    You need to know the HCO3 level to be sure it's purely respiratory alkalosis, but on the info given it looks like mild resp alkalosis. As a nurse, I'd want more info like how much exercise he used to get at home (sitting in chair watching tv all day?), why is he DNR (has he decided he's dying and there is no point getting up?), does he have an underlying infection making him feel feeble (increased WBC, lethargy etc) for example, a urinary tract infection or chest infection? I wouldn't use risk of infection if he already has WBC 19000 - there is probably an infection somewhere already.
    Sorry it's not very "official" advice, hope it helps your thinking process a bit.
  4. by   sweet tooth
    augigi, thanks for your input, including the other points you mentioned. I was wondering about using Risk for Infection when the evidence shows that he already has an infection.
  5. by   Daytonite
    A patient who is able to move around, but doesn't want to is either noncompliant or tired out. COPD'ers are often just tired out. Breathing is a struggle for them.

    To use Activity Intolerance the patient needs to have insufficient physiological or psychological energy to perform his ADLs. The related factors that NANDA has ascribed to this diagnosis include: bed rest or immobility, generalized weakness, an imbalance between oxygen supply and demand and a sedentary lifestyle. However, you also need to have evidence (patient data) to support this in the form of things like shortness of breath with activity, patient complaints of fatigue or weakness and changes in heart rates and blood pressure with activity. It might also support your patient's complaints that he doesn't want to get out of bed. Did he say why he didn't want to get out of bed? Do you have any of those other patient data items?

    You can't use Impaired Physical Mobility unless the patient has some physical or physiological cause that is limiting and restricting his ability to move. The data to support this would be things like him having limited range of motion and/or difficulty moving due to shortness of breath.

    Risk for Disuse Syndrome is a diagnosis you would only want to use if the patient had basically gone to bed and decided to stay there. This diagnosis is for someone who is going to deteriorate and become an invalid and is at risk for a whole battery of problems that come with being bedridden.

    Other than the elevated white blood cell count, does this patient have a documented diagnosis of an infection? If he does, then you cannot use Risk for Infection because he already has an infection. An infection is a medical diagnosis. If there is no documented medical diagnosis of infection then you can use Risk for Infection R/T chronic disease since the most likely source would be bacteria the lung.

    Is your COPD'er a pink puffer (emphysema) or a blue bloater (chronic bronchitis)? The reason I ask is because if he is a blue bloater, he's likely to have a lot of mucus production which would warrant a nursing diagnosis of Ineffective Airway Clearance R/T bronchospasm and excessive mucus production.

    You might also want to consider a couple of the self-care deficit diagnoses as well because of his fatigue or weakness.
  6. by   augigi
    Just realized I wrote "activity tolerance" in my first post.. doh.. I'm sure you knew what I meant
  7. by   I RN A
    I would do Impaired gas exchange or whatever you think is related to breathing and circulation first. Just remember Maslow's hierarchy: Airway,breathing, circulation, nutrition, mobility.