r/t fluid and exudate accumulation at the capillary-alveolar membrane

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Hi all!

I am writing a careplan for impaired gas exhange r/t fluid and exudate accumulation at the capillary-alveolar membrane. However, I am having trouble finding how one would assess this. What objective findings would I see to determine this is happening? Is it something I would auscultate and hear crackles or is there another way I could determine this is happening?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Is this about a real patient? What care plan resource are you using?

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Is this about a real patient? What care plan resource are you using?

Fake patient without any given data. I am using my nursing diagnosis manual with all the NANDAs. I'm just trying to figure out how I would assess the r/t. Is it something that be heard through a stethoscope or seen on an xray? I am starting my second semester of a BSN program, so still a baby student :)

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What happens at the site of the capillaries/alveoli? What happens if now you have fluid at the capillary/alveoli site (or what doesn't happen/is impaired?) If you understand that then you know what characteristics/"as evidenced by" to expect with this diagnosis :)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Fake patient without any given data. I am using my nursing diagnosis manual with all the NANDAs. I'm just trying to figure out how I would assess the r/t. Is it something that be heard through a stethoscope or seen on an xray? I am starting my second semester of a BSN program, so still a baby student :)

Ok what does your NANDA resource say about impaired gas exchange?

Each nursing diagnosis has 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
now how would you assess for these symptoms...you got this. Put your thinking cap on and tell me what you would assess.
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I would look at the ABGs, look at the pts appearance for pallor color or nasal flaring, and I would want to auscultate lungs for crackles - which is fluid. I guess I'm still thinking black and white. If xyz happens, you get this result. Is there an obvious answer that would say the or definitely has fluid accumulation?

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- First, you monitor the vital signs to obtain a baseline

- Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious sounds

- Use pulse oximetry to monitor oxygen saturation and pulse rate

- Monitor hemoglobin levels

- Assess for signs and symptoms of atelectasis: diminished chest excursion, limited diaphragm excursion, bronchial or tubular breath sounds, crackles, tracheal shift to affected side.

- Assess for signs and symptoms of pulmonary infarction: cough, hemoptysis, pleuritic pain, consolidation, pleural effusion, bronchial breath sounds, pleural friction rub, fever.

- Monitor ABGs and note changes

etc...etc...etc...

The book I am utilizing is "Nursing Care Plans Nursing Diagnosis and Intervention" by Gulanick/Myers

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1) There is no such thing a "a NANDA." And no handbook or other text has all of the NANDA-I approved nursing diagnoses with defining and related factors. (If they did, it would be a copyright violation).

So let's start over. Take out your NANDA-I 2015 – 2017, and go to page 204, which is where you will find the definition, defining characteristics, and related/causative factors for impaired gas exchange. Yes, you need to get the current book. It's not expensive, and you can get in 2 days from Amazon.

You will remember that to make a nursing diagnosis, you must have at least one approved defining characteristic and one approved related/causative factor. Helpfully, your NANDA-I gives you everything you need.

Impaired gas exchange

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar – capillary membrane.

So far, so good.

Defining characteristics : These are your "as evidenced by" criteria, at least one of which must be present for you to make this diagnosis. Note, you do not "choose" a diagnosis, you make a diagnosis based on data. Which you gather in your personal assessment! See how that works?

• abnormal arterial blood gases

• abnormal arterial pH

• abnormal breathing pattern (e.g., rate, rhythm, depth)

• abnormal skin color (e.g., pale, dusky, cyanosis)

• confusion

• cyanosis

• decrease in CO2 level• diaphoresis

• dyspnea

• headache on awakening

• hypercapnia

• hypoxemia

• hypoxia

• irritability

• nasal flaring

• restlessness

• somnolence

• tachycardia

• visual disturbance

Related factors: ( these are your causative factors, your "related to" of which you must have one of the following)

• alveolar – capillary membrane changes

• ventilation – perfusion in balance

Now, since I don't see anything at all that says, "fluid and exudate accumulation at the capillary – alveolar membrane," you can't call that a related factor in the nursing diagnosis that you make.

I understand what your thinking is, but you're doing something that you can't do. So your choice is to change your related-to phrase to one of two things:

• alveolar–capillary membrane changes, which you would assess by listening to see if there's fluid in the alveoli. How would you do this?

or

• ventilation–perfusion imbalance, if you have found in your assessment that a portion of this person's lungs is not being ventilated.

I don't usually give such complete answers to someone's homework question, but it's the beginning of the semester for a lot of folks, and it's clear that for whatever reason, your program has not yet impressed upon you the process and rationales for nursing diagnosis. This may not be your fault. However, this is, in fact, how it works. You are not allowed to riff on it otherwise.

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Thank you, anewdawnlvn2015! This is exactly what I was having trouble connecting.

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SunnyTrailRunner, I truly understand what you are going through in your first semester of nursing school. In my program, we did at least two to three or more care plans per week in the first semester . It is like speaking a different language, once you begin to learn it, it will become a bit easier to understand. :0) Hang in there.:up:

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Thank you, Grntea! This definitely helps me understand the process of writing careplans more easily. This is one of the careplans due on the first day of classes, before the semester even starts.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What Grntea gave you is right out of the NANDA nursing diagnosis book. There is a new addition this year.

Care plans are all about the patient and the patients problems. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

  1. Assessment
    (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)

  2. Determination of the patient's problem(s)/nursing diagnosis
    (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

  3. Planning
    (write measurable goals/outcomes and nursing interventions)

  4. Implementation
    (initiate the care plan)

  5. Evaluation
    (determine if goals/outcomes have been met)

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