ChloeTheWise

Thank you so much for the help!! :) It makes much more sense now and I think the next one will be much easier.

So, I am sure you know about S.M.A.R.T Goals, as we have to write them for our patients-- but when it comes to studying, write some of those goals for yourself so you know whether or not you have achieved them! Make your studying goals Specific, Measurable, Achievable, Realistic, and Timely. I don't know if you ever study with groups of people, but it is so helpful to keep myself on track when I study with a group and we each bring a specific section to test each other. It's a great way to measure whether or not you have learned the material when you can talk through it with others, and even to teach somebody else! Make sure to give yourself study breaks so you don't get overwhelmed too! :) Hope things are looking up for you!

oh.... wait a second, the r/t in the book would have to be the environmental factor of smoking, right? So.... Ineffective Airway Clearance r/t smoking AEB excessive sputum production and dyspnea upon exertion?

I think my patient has Ineffective Airway Clearance caused by excessive sputum. I can see that the airway clearance is an issue due to the patient's chief complaint of dyspnea upon exertion. Ineffective Airway Clearance r/t excessive sputum production AEB dyspnea upon exertion

I have Ackley and Ladwig Nursing Diagnosis Handbook, Ninth Edition. With the consideration that my patient has no history of COPD or lung disease, I am really struggling to understand how I could make a care plan focused on that. The assessment that I did revealed no issues with ADLs, no history, no abnormal anything, in essence. All I have to focus on is the smoking, cough with green phlegm, and shortness of breath with activity (when walking from upstairs to downstairs, and when trying to exercise) and the "hollow resonance" I was talking about was not intended to mean that it was abnormal-- what I meant by that is the normal sound the lungs should sound in response to percussion. Maybe I worded that wrong. So, considering ADPIE, all those things I just explained were my "A" for Assessment. Her main concern was the shortness of breath; my main concern was the phlegm being green which indicates infection, but she doesn't have any history of this, so that is why I am stuck. I am concerned about possible infection as well as her airway (considering her ABC's)... If I'm not making sense please let me know and I will try to expand on it!!

Sorry-- I was under the impression that it had to be a wellness diagnosis, but I discovered today that I had the wrong understanding. The diagnosis can be anything. Current, at risk for, or wellness. So with that in mind, "Impaired tissue perfusion r/t smoking AEB S.O.B with activity" might be an option... is that a place to start? Is there anything wrong with this diagnosis?

Hello community! I am a first semester nursing student, so imagine me as a child trying to learn Nursing Diagnosis and Care plans :) I could use some assistance! For a class assignment, we were split into pairs and had to listen to ask about health history, do a physical examination including inspection, palpation, percussion, auscultation, and then find subjective and objective information about the patient. Since it was a classmate, we had to come up with her "chief complaint." I am having difficulty creating a wellness diagnosis and the plan to go along with it. Chief complaint: S.O.B. and cough with activity Health History: Smoker on average 10 cigarettes/week, Currently has a productive cough with green phlegm. Objective findings were all "normal" for this hypothetical patient. Thoracic cage symmetrical, Respiratory rate 15 breaths/minute and even, skin pink and intact, alert and oriented x3... Clear in all lung fields, no adventitious sounds, hollow resonance, no lumps, and trachea is midline to the body... If I were trying to write a WELLNESS diagnosis, can I do this: "Readiness for enhanced self-Health management R/T Patient expresses desire to improve breathing capacity" Then the patient outcome would be "patient will explain 3 ways to improve breathing capacity before discharge" ..? I also thought "Risk for ineffective airway clearance r/t discolored sputum production." Would this work for a diagnosis if I were aiming for Risk? (we are supposed to come up with a Wellness one so I decided to avoid this for the most part...) My biggest confusion then, comes from the Nursing Intervention and Rationales. My understanding at first was that we are supposed to create ways to show a patient the resources they need, or how to use certain tools. Example-- Incentive spirometer. The reason I am confused is that there is no "Incentive Spirometer" option in my NANDA textbook. Does this make sense, and can somebody help walk me through this so I can understand?? I see an option in the textbook "help the client maintain existing support and seek additional support as needed" and that is under the category Self-Health Management, but I just seem to be missing a step here somewhere! Thanks for the help! :)