runner125

I've decided to use Ineffective airway clearance as my priority diagnosis... just having a difficult time determining the right R/T. I was originally going to use excessive secretions, but now I feel it's more R/T her inability to be aware enough to cough, plus she is unable to move herself freely in bed, etc. So would neuromuscular impairment apply or impaired resp muscle function maybe?

the patient had the trach put in because she went into resp failure as a result of the sepsis. Now that the trach has been taken out, her O2 has been 99/100 on room air and she has breathing tx with RT daily. She is having a productive cough and her lung sounds are diminished, but clear. I agree with you as well that there should be some sort of resp diagnosis, but given the data I have, I can't see one. As far as the activity intolerance goes, the interventions I came up with are: Assess VS before and after activity throughout shift, noting rate, rhythm, depth of resp. Perform passive ROM exercises and ADLs with patient assistance when appropriate, alternating activity with rest throughout shift. Teach patient energy conservation techniques, such as controlled breathing, during activity by end of shift. Do these sound ok? I pretty much know what the interventions would be for activity intolerance, I'm just having a hard time putting it into words. Since she has end stage renal failure, she doesn't urinate at all. No foley cath either, but she does have a rectal tube in place.

I am starting a care plan and am having difficulty formulating my diagnoses... here's the assessment data: Hx end stage renal failure (with dialysis), DM, HTN, GI bleeding, anemia, sepsis Original Dx of sepsis, ALOC now: her sepsis is clear, although she did have to be intubated as a result (resp failure)... the pt had her trach taken out and is getting ready to be discharged. she's positive for c-diff, VRE. NPO, has peg tube, picc line, central line for dialysis, rectal tube. is not able to move her left side at all... she has foot drop, and contractures of both hands. She is able to raise her right hand, and move her right leg. Is able to communicate (speak), but can be difficult to understand (garbled). She has a stage 1 pressure ulcer on her coccyx (circular in shape, 10cm diameter, reddened area, no open areas). Here's what I'm thinking... I want to use activity intolerance as her #1 diagnosis but am having a hard time with the interventions... she's on bedrest, isn't able to move on her own. When moving her up in bed, turning her from side to side to perform AM care, she has dyspnea and gets tachypneic. She gets visibly agitated when being moved (which looks more like it hurts to be moved). Other diagnosis include impaired skin integrity, impaired physical mobility, self-care deficit, risk for infection, but I feel activity intolerance is most appropriate as #1... does this sound correct and what can I do as far as interventions? I'm having a hard time putting it into words... I tried to perform all necessary movements in the beginning of the shift and alternated activity with rest. Assessed her tolerance to movement by checking the extent of ROM movements. Reassured her when she seemed to get agitated with moving. Any ideas on wording?

I agree with you that the absence of a cough can be considered an ineffective cough since he really should be coughing. I witnessed his breathing treatment with RT and thought it was odd that he never coughed once. I discussed my care plan with my instructor today and have changed my diagnoses a bit: Ineffective airway clearance R/T excessive secretions in lungs S/T COPD AEB diminished lung sounds in all lobes, irregular and labored respirations, and absence of cough activity intolerance R/T imbalance between oxygen supply and demand AEB dyspnea with exertion, increased HR with exertion, and patient reports needing to multiple breaks when performing ADLs Ineffective peripheral tissue perfusion R/T interruption of venous flow S/T bilateral DVT AEB capillary refill of 4sec, 1+ pedal pulses bilaterally, and mottling of skin on lower extremities bilaterally. Impaired skin integrity R/T inflammatory response S/T cellulitis AEB local erythema, pruritus, and scant purulent drainage across entire left lower extremity and bilateral upper extremities, 2+ edema of LLE and 1+ bilateral upper extremities (still having difficulty describing this-- basically just red, hot, swollen, itchy all over with minimal drainage) Ineffective health maintenance R/T ineffective individual coping AEB history of multiple hospitalizations within past month for persistence of symptoms, inability to verbalize understanding of treatment regimen, and statement of lack of interest in improving health behavior. Does this sound better??

i was hesitant to use ineffective airway clearance because he didn't have any adventitious lung sounds, just diminished. obviously as a COPDer, he's prone to excessive secretions in general, I just didn't witness any issues with it when I took care of him.

he's not forgetful or confused at all... like you said, he's just a control freak. he doesn't like having anyone tell him what to do. he resists anything the nurses tell him. i'm actually surprised he's even as mobile as he is, given everything he has... he even had an MI in 1996. so activity intolerance would be #1 diagnosis, followed by a circulation diagnosis?

do you think decreased cardiac output would be a more appropriate #1 diagnosis? I was going back and forth between decreased cardiac output, ineffective breathing pattern (which looking back, is also addressed in activity intolerance), and impaired gas exchange. This guy obviously has respiratory/cardiac issues all around. He's on oxygen 2L via NC, and has to be continually reminded to keep NC on. even with the oxygen, he sats at around 92%. Thanks for your help!

I need a little bit of help with my care plan... need 5 diagnoses, here's some info about my patient-- HX: admitted 2 wks ago with primary dx of chest pain r/o MI was diagnosed with bilateral DVT 2 months prior, been admitted 2 more times since due to chest pain, SOB, similar symptoms because patient doesn't take meds, give himself shots, when asked why, he cannot provide good explanation. HX of HTN, CAD, COPD, hyperlipidemia has cellulitis of left LE with edema 2+, pain, erythema. was put on vancomycin for cellulitis, had allergic reaction to medicine and now has rash on left lower extremity, bilateral upper extremities and across chest. has dressings on these sites. States it's very itchy, patient continues to scratch despite being told many times that this will cause infection. drs think rashes on arms may have cellulitis as well. chest pain is now gone. continues to have mild dyspnea with exertion, diminished lung sounds, tripod positioning and pursed lip breathing. he is visibly restless, pain at 5/10 on extremities because of inflammation. when asked about not taking medications, he said that it's "annoying" to have to remember to take pills and give shots. these are the five diagnoses I have: Ineffective breathing pattern R/T respiratory muscle fatigue S/T COPD AEB diminished lung sounds in all lobes, tripod positioning for breathing, labored, irregular respirations with pursed lip breathing, and dyspnea with exertion. Impaired skin integrity R/T inflammatory response S/T cellulitis AEB local erythema and disruption of the dermis tissue, tenderness and pain at left lower extremity, bilateral upper extremities, and across entire chest. Acute pain R/T tissue inflammation S/T cellulitis AEB patient stated pain at 5/10 (lower left extremity, bilateral upper extremities and classified as constant throbbing), visible restlessness, and facial grimacing with extremity movement. Activity intolerance R/T imbalance between oxygen supply and demand AEB dyspnea with exertion, increased heart rate with exertion, and patient reports needing multiple breaks when performing ADLs. Noncompliance R/T adherence to treatment plan AEB multiple hospitalizations within month due to reoccurrence of symptoms, pt unable to verbalize understanding of the necessity of treatment plan, and direct observation of patient's noncompliance with treatment plan (continually scratching rash areas). Is this the right order and do these diagnoses make sense??