Risk for, ect.

is it true you can't have more than one "related to" for risk for diagnoses?

no! the "related to" factors in a nursing diagnostic statement are directly linked to the symptoms (defining characteristics) the patient has that fit the diagnosis. the etiology, or related factors ("related to" items) classify what is causing some of the defining characteristics.

can you not have "secondary to" for risk for diagnoses?

this is something that you would need to consult your nursing instructors about. you are talking about what goes into a nursing diagnostic statement. usually, the nursing program or instructors within a nursing program dictate how they want the nursing diagnostic statements structured. so, anything is possible. the answer is that: it is possible to have a "secondary to" placed onto the "related to" part of the risk for nursing diagnostic statement; it is also possible not to have a "secondary to" placed onto the "related to" part of the risk for nursing diagnostic statement. it all depends on what the rule makers of your care plans say they want you to do.

should i add smoking secondary to copd for the first nursing diagnosis?

no. if you look at the nanda related factors listed with this particular diagnosis, you will see that both the smoking and copd are etiological factors. copd is actually a very vague description of lung disease. copd really needs to be more specifically defined by the doctor and hopefully that was done and can be found in the doctor's history and physical or review of systems information of the patient's chart. copd presents as either (1) chronic obstructive bronchitis, (2) chronic obstructive asthma, (3) emphysema, or (4) chronic bronchitis with emphysema. this is one of the reasons that i believe nanda permits the use of copd as a related factor with nursing diagnostic statements: it's not a clearly defined medical diagnosis. you should re-write this nursing diagnosis as: ineffective airway clearance r/t copd and smoking. as you can see, you will have two related factors for this nursing diagnosis. this goes back to your first question i answered above. to add a "secondary to" element to this nursing diagnosis you would need to know the medical diagnosis, so for example, it might then be written as: ineffective airway clearance r/t copd and smoking secondary to emphysema.

can you have two similar nursing diagnoses as i have for the first two?

they may seem to be similar to you because they both refer to the process of breathing and the airway. however, if you look at their definitions, related factors and defining characteristics you will see that there is a difference between them. the definition of ineffective airway clearance is: "inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway" (nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international, page 5). the definition of impaired gas exchange is: "excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane" (nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international, page 94). the diagnosis of ineffective airway clearance is talking about physical gunk mucking up and obstructing the bronchus and making the passage of air difficult. impaired gas exchange is referring to problems with oxygen and carbon dioxide being exchanged for each other in the alveoli of the lung. these are two very different things. with ineffective airway clearance your nursing interventions are designed to get the sputum cleared out of the airway. with impaired gas exchange your nursing interventions are designed to maximize oxygen/carbon dioxide gas exchange in the alveoli and to keep the patient's oxygen saturation levels as normal as possible. here are links to websites that contain not only the definitions, but the related factors and defining characteristics of these two nursing diagnoses:

• [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_002.php
  
• [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_032.php

you can include the use of oxygen as a nursing intervention if the doctor has ordered it (this would be a collaborative intervention). however, you can still include it as an intervention if it hasn't been ordered and you word it tactfully, such as, "assemble equipment necessary to administer oxygen in the event that o2 sats drop below 80%", for example.

i would prioritize and re-sequence the nursing diagnoses as follows:

1. impaired gas exchange
   
2. ineffective airway clearance
   
3. imbalanced nutrition: more than body requirements
   
4. anxiety
   
5. risk for infection
   
6. risk for constipation
   
7. risk for falls