Pleural Effusion Nursing Diagnosis

[atm24]

Hi! I am working on a care plan and I am having a difficult time coming up with 2 nursing diagnosis. My pts main problems are pleural effusion and pancreatitis. The RR were within normal limits. O2 was 30. She is a smoker but was on nicotine patches while in the hospital. Wheezing on left lung base. A CT showed significant left sided effusion, small right sided effusion, mildly enlarged heart, abnormal liver and likely pancreatic pseudocysts. BUN was low, glucose was high, albumin was low, ALT was high. Any help would be appreciated! Thank you so much!

[Rose_Queen, BSN, MSN, RN]

Nursing diagnoses rely on the nursing assessment. What did your assessment about the patient tell you? While some nursing diagnoses may be related to the medical diagnosis, you never make a care plan based directly on the medical diagnosis. Was the patient in pain? What about mobility? Mental/emotional status?

[atm24]

Yes, the patient was in pain. She complained of pain of a 4 on a scale of 0-10 in her midback. She stated that she had been experiencing that pain for the past 2 months. She was able to move herself and do her ADLs without assistance. She was able to get out of bed and walk with no help. She was on meds for depression. Everything with the integumentary system was fine. For cardiovascular system the rhythm was sinus tachycardia with a rate of 109. Oxygen via NC of 2L/min. Non-productive cough. Wheezing at left lung base. Diarrhea twice two days before clinical. Hematuria which pt stated has been occurring since childhood but causes no problems and the doctors do not know why it occurs. PERRLA. Good reflexes. Score of 15 on glasgow coma scale. Muscle strength 5/5, bilaterally symmetric with full resistance to opposition.

[Rose_Queen, BSN, MSN, RN]

Okay, so from that information what do you think are the patient's priorities?

[atm24]

I'm thinking something along the lines of ineffective airway clearance r/t decreased lung expansion secondary to pleural effusion aeb CO2 level of 30. I'm not sure if the CO2 level is correct evidence for that diagnosis, though. I'm also thinking about acute pain r/t obstruction of the pancreatic ducts secondary to pancreatitis aeb verbal report of pain of a 4 on a scale of 0-10.

[AliNajaCat]

A PaCO2 of 30 is hypocapnia, not hypercapnia, so that's not it. She has to have another reason for hyperventilation, especially if she has decreased pulmonary volumes due to her effusion. According to the current NANDA (2015-2017), impaired gas exchange may include decreased CO2 level, but you also have to know that hypoventilation causes hypercapnia, not hypocapnia. So, is she hyperventilating because of pain? Is it because she is hypoxemic (a very bad late sign)? Does she have a metabolic acidosis and hyperventilating to blow off CO2 in an attempt to compensate for that?

You cannot ask for a nursing diagnosis for a medical diagnosis, no you can't, even though your "handbook" is set up that way. Don't believe me? What about the people who are admitted with an unknown medical diagnosis? Do you say, "OK. No nursing diagnosis for you!"? Or what if your neat little handbook list for, say, diabetes doesn't include some nursing diagnosis for oh, impaired religiosity, which turns out to be very important to the patient /family? This is only one reason why I am never happy with those "nursing diagnosis handbooks," in addition to the fact that approved nsg dx are published q2 yrs, and it takes at least 2 years to get a textbook into print (I know, I've done it), and so your handbook with a 2013 date is already at least five years out of date today. They do not teach you how to think like a nurse, as evidenced by (defining characteristic) the fact that you're still working on a medical diagnosis, not a nursing assessment for her.

This is not your fault, but you do have to get beyond it. Meanwhile, here's some info on how to look at all of her blood gases to have a better idea of her acid/base balance. And get the NANDA-I and look up diagnoses you think you can make (not "pick") based on the defining characteristics ad approved related (causative) factors. That's how you'll learn to think like a NURSE, not a physician appendage.

See post #4 for an excellent discussion of ABGs and pH.

[AliNajaCat]

atm24 said:

Yes, the patient was in pain. She complained of pain of a 4 on a scale of 0-10 in her midback. She stated that she had been experiencing that pain for the past 2 months. She was able to move herself and do her ADLs without assistance. She was able to get out of bed and walk with no help. She was on meds for depression. Everything with the integumentary system was fine. For cardiovascular system the rhythm was sinus tachycardia with a rate of 109. Oxygen via NC of 2L/min. Non-productive cough. Wheezing at left lung base. Diarrhea twice two days before clinical. Hematuria which pt stated has been occurring since childhood but causes no problems and the doctors do not know why it occurs. PERRLA. Good reflexes. Score of 15 on glasgow coma scale. Muscle strength 5/5, bilaterally symmetric with full resistance to opposition.

Almost all medical. What's your nursing assessment?

[Kuriin, BSN, RN]

If I recall correctly, OP, ineffective airway clearance means that there's an obstruction blocking your airway. You may want to look into impaired gas exchange? Was the person on albuterol for their wheezing?

[AliNajaCat]

Wait, did you say O2, oxygen, PaO2 was 30? This is a medical emergency. She is almost dead, so you have bigger fish to fry. Or did you mean she was on FIO2 of .30, 30% inhaled oxygen. In which case, what were her labs for that? SpO2 or PaO2?

I was assuming that was a typo for CO2. At very least, let this be a lesson in always using UNITS OF MEASUREMENT for things unless the context is absolutely clear. Please clarify.