please guide-nursing diagnosis

[gaajr1, RN]

Hello Everyone,

We had our first clinical and one of our assignments was to take a health history, but only the first page of the entire form. Basing on this and the admitting diagnosis we have to make our nursing diagnosis. This is my first time plus have limited info. If I'm not asking too much, can anyone tell me if I'm on the right track?

Admitting diagnosis: CHF

Smoked for 60yrs.

Health history: Heart attack 5yrs back; breathing problem since 4yrs.

Major health problem: "breathing, keeps me from doing things".

Past illnesses: NIDDM, CVA, HTN, COPD

Maslow: oxygen-breathing hard, panting, using accessory muscles,

restless, oxygen-4 NC, edema

emotional state: "not happy"; "unable to do anything"; "people telling me I don't do enough to get better".

Grief stage: "angry at myself, not stopping to smoke earlier"

Family history: HTN, NIDDM, smoking

medications: pepcid, ASA, nitroglycerin, noruase, zyprexa, lasix, coreg, warfarin, simvastatin, cozaar, amrodarone, glipizide.

My nursing diagnosis: Impaired gas exchange r/t altered oxygen-carrying capacity of blood as evidenced by restlessness, breathing hard, panting, oxygen 4, using accessory muscles.

Also, can I use excess fluid volume r/t decreased cardiac output as manifested by edema, shortness of breath?

Am I totally off? Daytonite, I have your explanation with me, but when it actually comes to implement, I'm still shaky. Thank you and look forward to the input.

[Daytonite, BSN, RN]

the patient has impaired gas exchange ([color=#3366ff]impaired gas exchange) because he has the following symptoms of it: restlessness, breathing hard, panting, using accessory muscles to breathe (oxygen at 4l is a treatment). the etiology could be stated more definitively. there are only two etiologies connected with this diagnosis and both involved things that interfere with gases passing through the alveolar membranes: ventilation perfusion imbalances (more or less oxygen/carbon dioxide passing back and forth across the alveolar membranes for any number of reasons, or these imbalances specifically due to permanent alveolar-capillary membrane (tissue/anatomical) changes (as occur in such disease as copd and fibrosis). this is why you need to know the pathophysiology of the patient's underlying diseases. my guess is that the patient's lung problems are due to the copd changes in his lungs. he also has heart problems. a prior heart attack and cva, hypertension and some of the medications he is on would suggest that he is constantly fighting off some degree of heart failure. his fluid volume excess is because of the heart failure.

i would reword the nursing diagnosis to say impaired gas exchange r/t alveolar-capillary membrane changes secondary to copd aeb restlessness, breathing hard, panting, and using accessory muscles to breathe. he also has decreased cardiac output r/t altered contractility aeb difficulty breathing and edema ([color=#3366ff]decreased cardiac output) and anxiety r/t change in health status aeb patient's statements "not happy", "unable to do anything", "people telling me i don't do enough to get better", and "angry at myself". (anxiety)

[gaajr1, RN]

Thanks a lot Daytonite! Time and again you have been advising students to know the pathophysiology and I did read about it. Infact, after I read, the patient's condition made more sense to me.

My problem while writing the diagnosis was choosing the etiology correctly. I was very hesitant. I think the more I do, I will get confidence. After you rewrote the diagnosis, I can see where you are going.

Thanks a lot!

[gaajr1, RN]

Daytonite, as I had mentioned I read the pathophysio of CHF but did not read about COPD.

Please tell me if I understood it right; it is good know the pathophysio of the main health concern and also any underlying problems (other medical conditions the patient has)?

Thanks!

[Daytonite, BSN, RN]

with copd the tissues in the lung become damaged so oxygen and carbon dioxide transport is compromised permanently. that is what causes the alveolar-capillary membrane changes. in a condition like pneumonia, it is the built up mucus and byproducts of the inflammation causing the problem, but it is a temporary and reversible condition. it helps to have a few of these patients to see all these symptoms.

see https://allnurses.com/forums/2833405-post5.html

[kgh31386, BSN, MSN, RN]

you might also try Knowledge deficit because he admits the things he does wrong. I'm not saying daytonite is wrong(her years of experience vs my 1 year of nursing school haha). but i was gonna say the impaired gas exchange would come from the CHF. the fluid starts to back up into the lungs(pulmonary edema)..the tissues in the lungs become saturated with fluid which won't allow you to get in any oxygen.