Pneumonia Priority Nursing Diagnoses

nurseprnRN, BSN, RN · Aug 4, 2014

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.

Mancoww · Aug 4, 2014

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..

Esme12, ASN, BSN, RN · Aug 5, 2014

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.

Mancoww · Aug 9, 2014

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 · Aug 10, 2014

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.?