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Pneumonia Priority Nursing Diagnoses

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by Mancoww Mancoww (New) New

Hi,

I am making an academic essay but I am having trouble trying to sort out the priority nursing diagnoses for my case study and their rationale. Here is the scenario (pneumonia):

"Ms. J, a 52 year old librarian, states she "feels dizzy... hard to get my breath and my chest is sore from coughing".

--- I am also having trouble as to why "chest is sore from coughing" would be considered as a red flag for pneumonia.

Thank you very much for your help.

It is tough to do care plans when you are working off a scenario and not with an actual patient you can assess, but this one seems fairly straightforward. Think about what is happening when someone has pneumonia, and why the patient would have those symptoms. Also, if you remember your ABCs you should be able find your priorities. What do you think your first priority should be? TOS states we don't give you the answers outright, but let us know your thoughts and we will help you work through it.

"Ms. J, a 52 year old librarian, states she "feels dizzy... hard to get my breath and my chest is sore from coughing".

--- I am also having trouble as to why "chest is sore from coughing" would be considered as a red flag for pneumonia.

Here are the priority nursing diagnoses I've come up:

Impaired gas exchange r/t excessive mucus as evidenced by report of dizziness and difficulty breathing

Rationale: dizziness and difficulty breathing indicate hypoxemia

2. Acute pain related to muscle strain from excessive coughing as evidenced by report of sore chest from coughing

Rationale: I can't seem to figure out the right rationale for this. I'm thinking of maybe due to sore chest, Ms. J might not be able to effectively cough??

I thought of including potential for ineffective airway clearance related to excess mucus as evidenced by sore chest from coughing?? I'm not quite sure if this makes any sense.

Thank you very much for your help.

Edited by dianah
formatting

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Welcome!

I hate these things....it is so hard when there is no assessment data to use as a guideline.

What semester are you?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

"Ms. J, a 52 year old librarian, states she "feels dizzy... hard to get my breath and my chest is sore from coughing".

--- I am also having trouble as to why "chest is sore from coughing" would be considered as a red flag for pneumonia.

It this all the information the school gave you? If not include it ALL here please then I can help

I'm in the medical-surgical semester. ;)

Here's the whole scenario:

You're an RN working in a general medical ward and have been asked to accept a patient from a GP with a provisional diagnosis of pneumonia. Ms J, a 52 year old librarian, states she "feels dizzy... hard to get my breath and my chest is sore from coughing". On inquiring further you learn that Ms J had a cold last week and generally smokes 1/2-1 packet of cigarettes a day. She had a previous episode of bronchitis 6 months ago. Consider the nurse's role in relation to Ms Saxon's on-going assessment, management and discharge considerations.

Here's the assessment data:

- appropriate nursing diagnoses identified to provide holistic care

- appropriate selection of 2 priority nursing diagnoses, with specific interventions

-clear rationale for the priority nursing diagnoses and interventions

- comprehensive discussion on the evaluation of the interventions.

The Nursing Assessments that I have mentioned in the essay are:

-Rapid Assessment

- Monitor Vital Signs-

-COLDPSA pain assessment for her sore chest

- Posterior Chest Examination

- Psychosocial Assessment

- Nutritional Assessment

thanks.

Edited by Mancoww
needs more info

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Ok..."ward" you must not be in the US. I have seen these type of assignment from students in NZ or AU.

You do use NANDA.... yes?

The question is....does she have COPD or pneumonia or both?

Ms J, a 52 year old librarian, states she "feels dizzy... hard to get my breath and my chest is sore from coughing". On inquiring further you learn that Ms J had a cold last week and generally smokes 1/2-1 packet of cigarettes a day. She had a previous episode of bronchitis 6 months ago. Consider the nurse's role in relation to Ms Saxon's on-going assessment, management and discharge considerations.
First I would look up pneumonia are see what the pathohysiology is and what are the complications.
he Nursing Assessments that I have mentioned in the essay are:

-Rapid Assessment

- Monitor Vital Signs-

-COLDPSA pain assessment for her sore chest

- Posterior Chest Examination

- Psychosocial Assessment

- Nutritional Assessment

thanks.

As per the standard you should always do a head to toe assessment. Why would you only assess the posterior chest? Wouldn't you assess anterior lung sounds as well? With her c/o dizziness wouldn't her safety be a concern as well? Would risk of falls be a consideration?

What care plan resource are you using?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Impaired gas exchange r/t excessive mucus as evidenced by report of dizziness and difficulty breathing

According to NANDA...Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

Defining Characteristics: Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances

Related Factors (r/t): Ventilation-perfusion imbalance; alveolar-capillary membrane changes

So....how does this definition fit your patient?

Excessive secretions would be.....Ineffective Airway Clearance:Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Defining Characteristics: Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed

Related Factors (r/t)

Environmental

Secondhand smoke; smoke inhalation; smoking

Obstructed Airway

Airway spasm; excessive mucus; exudate in the alveoli; foreign body in airway; presence of artificial airway; retained secretions; secretions in the bronchi

Physiological

Allergic airways; asthma; COPD; hyperplasia of the bronchial walls; infection; neuromuscular dysfunction

How does this apply to your patient?

Hi,

I'm from NZ and yes, I am aware of NANDA. We have been informed that Ms. J has pneumonia and our lecturers have only discussed posterior chest assessment. I will include a falls risk assessment as part of her comprehensive assessment-thank you for this.

Anyway, here are the 2 priority nursing diagnoses I have come up:

1. Impaired gas exchange related to altered oxygen supply as evidenced by Ms. J reporting that she feels dizzy and short of breath.

Rationale: Dizziness indicate hypoxemia, putting Ms. J at risk of respiratory failure.

Interventions: semi-Fowler's position and encourage the use of pursed-lip breathing to facilitate oxygen diffusion and optimal lung expansion. Encourage Ms. J to rest and avoid over exertion to reduce oxygen demands. Administer oxygen as prescribed.

How do I evaluate the interventions? Is it just like: Ms. J reports an improvement on her dizziness, improved vital signs?

2. Ineffective airway clearance related to the accumulation of sputum as evidenced by inability to cough up phlegm due to pain upon coughing

Rationale: Retained secretions can obstruct airways, leading to an impaired gas exchange.

For the interventions of ineffective airway clearance, can i include "discourage smoking to prevent an increase in mucus production and improve ciliary function" although smoking is not mentioned in the diagnosis? I've discussed smoking as a contributing factor in my essay.

Thank you.

Edited by Mancoww
more info

2. Ineffective airway clearance related to the accumulation of sputum as evidenced by inability to cough up phlegm due to pain upon coughing

Rationale: Retained secretions can obstruct airways, leading to an impaired gas exchange.

Thank you.

I think "ineffective airway clearance related to the accumulation of mucus as evidenced by excessive coughing" is better.

Edited by Mancoww
quote

ArrowRN, BSN, RN

Specializes in Med Surg, Vascular, E.N.T. Has 3 years experience.

Hi,

How do I evaluate the interventions? Is it just like: Ms. J reports an improvement on her dizziness, improved vital signs?

For the interventions of ineffective airway clearance, can i include "discourage smoking to prevent an increase in mucus production and improve ciliary function" although smoking is not mentioned in the diagnosis? I've discussed smoking as a contributing factor in my essay.

Thank you.

Evaluations are to determine whether or not what you did for your patient worked. If it worked the patient will become better if not the patient becomes worse.

There are quite a few interventions you can do for someone with ineffective airways clearance, look these up. Also remember interventions need to be nursing actions that are measurable and attainable. Discouraging someone from smoking or recommending a smoking cessation program is good teaching for the long term stable pt but unrealistic in this case...for

1. It will not provide immediate assistance to your patient and

2. Think will you be in a state to accept this teaching if you were short of breath and dizzy? therefore its not a priority for your dizzy patient. What else can you do?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

1. Impaired gas exchange related to altered oxygen supply as evidenced by Ms. J reporting that she feels dizzy and short of breath.

Rationale: Dizziness indicate hypoxemia, putting Ms. J at risk of respiratory failure.

Interventions: semi-Fowler's position and encourage the use of pursed-lip breathing to facilitate oxygen diffusion and optimal lung expansion. Encourage Ms. J to rest and avoid over exertion to reduce oxygen demands. Administer oxygen as prescribed.

How to do document the altered oxygen supply? Do you have ABG's? Do you have an O2 Sat? The dizziness can be caused from coughing, vagal response to pain, hyperventilation due to anxiety and constant coughing. How are you documenting the Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane? Does pneumoniacause an issue with Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane?

Defining Characteristics: Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances

The defining characteristics are the "symptoms" that the patient presents with that fits the definitions. Here in the US the student would have to have "proof" that the air exchange is compromised. By saying that the gas exchange is impaired/altered you have to have "proof. What is your proof here?

It might be better to say...impaired gas exchange R/T oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane AEB diagnosis of PNA and patient complaints of cough/secretions, SOB and dizziness.

Have you addressed her pain?

Remember too that the lungs' priority job is getting CO2 out, and getting O2 in is secondary. Yes, it is, you can look it up. Hypoxia is an earlier sign than hypercarbia.

How to do document the altered oxygen supply? Do you have ABG's? Do you have an O2 Sat? The dizziness can be caused from coughing, vagal response to pain, hyperventilation due to anxiety and constant coughing. How are you documenting the Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane? Does pneumoniacause an issue with Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane?

The defining characteristics are the "symptoms" that the patient presents with that fits the definitions. Here in the US the student would have to have "proof" that the air exchange is compromised. By saying that the gas exchange is impaired/altered you have to have "proof. What is your proof here?

It might be better to say...impaired gas exchange R/T oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane AEB diagnosis of PNA and patient complaints of cough/secretions, SOB and dizziness.

Have you addressed her pain?

hi,

Can i say 'impaired gas exchange related to impaired diffusion of gases associated with accumulation of mucus AEB report of dizziness and SOB'?

So her 'chest pain related to muscle strain from exessive coughing AEB report of sore chest from coughing' is considered a priority? and the ineffective airqay clearance is not a priority?? sorry i'm a bit confused..

Edited by Mancoww
more info

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

You can have more than one priority. Here in the US pain is a priority...and if it is contributing the the inability to clear the airway..then yes it is important. It is difficult to assist students from other countries for I am unfamiliar with the teachers expectations. Another member says it best...

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

As for your statement...
Can i say 'impaired gas exchange related to impaired diffusion of gases associated with accumulation of mucus AEB report of dizziness and SOB'?
Just because someone has a cough doesn't mean they have increased mucous. Does your scenario mention that the patient has thick tenacious secretions that they cannot expel causing a decrease in oxygen delivery? If so then you must have evidence of this....description of the sputum, O2 sat, or ABG's. You keep mentioning dizziness...how do you correlate dizziness with impaired gas exchange? Where in the NANDA defining characteristics does it mention dizziness as a characteristic?
Defining Characteristics: Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances
Just because they patient has pain from coughing doesn't mean the cough is productive or that there is impaired air exchange as per the NANDA definition. But what would? The infiltrates, atelectasis, or consolidation from the pneumonia on the chest x-ray?

I would associate the dizziness as a safety risk to the patient.

So her 'chest pain related to muscle strain from exessive coughing AEB report of sore chest from coughing' is considered a priority?
Yes...especially if she is resisting the cough to expel mucous causing a further issue with clearance of the airway... a clear airway is a priority.

Hi,

Thank you, it all makes sense now. I've chosen impaired gas exchange and pain as my priority nursing diagnoses. Thanks everyone for the help!

Episteme

Specializes in Education, research, neuro. Has 43 years experience.

Hi,

Thank you, it all makes sense now. I've chosen impaired gas exchange and pain as my priority nursing diagnoses. Thanks everyone for the help!

Mancoww, I'd like to tag onto what GrnTea said and comment on Esme's mention of the Defining Characteristics

My question is this. How can you make this diagnosis (impaired gas exchange) without some essential numbers? Specifically, %sat and/or PaO2, (and both of those numbers are useless unless we know what FiO2 she's breathing) and PaCO2. Sometimes serum HCO3- can provide useful data as well.

You have no information to tell us what is happening at the alveolar capillary membrane. (Unless I missed it which is always a possibility because I need trifocals when reading the computer screen... big sigh!)

At the end of the day, you could be right in your diagnosis... (because the patient has pneumonia, after all), but if you have zero information about respiratory gas exchange, you are required to be agnostic about this diagnosis.

I like to say, you cannot make a nursing diagnosis in a fact free zone. You have no objective about her levels of oxygen and carbon dioxide. None. Zip. Zero. So until you do, you cannot use this diagnosis.

You COULD however, legitimately say "RISK FOR impaired gas exchange." And if you do, your priority actions would be "GET MORE INFORMATION!!!" Like, vital signs? % sat on room air? %sat with ambulation, etc., etc.?