Nursing Diagnosis Essay

1149 words - 5 pages

Nursing Diagnosis I
Nursing Diagnosis I for Patient R.M. is ineffective airway clearance related to retained secretions. This is evidenced by a weak unproductive cough and by both objective and subjective data. Objective data includes diagnosis of pneumonia, functional decline, and dyspnea. Subjective data include the patient’s complaints of feeling short of breath, even with assistance with basic ADLs. This is a crucial nursing diagnosis as pneumonia is a serious condition that is the eighth leading cause of death in the United States and the number one cause of death from infectious diseases (Lemon, & Burke, 2011). It is vital to keep the airway clear of the mucus that may be produced from the inflammatory response of pneumonia. This care plan is increasingly important because of R.M.'s state of functional decline; he is unable to perform ADL and to elicit a strong cough by himself due to his slouched posture. Respiratory infections and in this case, pneumonia, will further impair the airway (Lemon, & Burke, 2011). Because of the combination of pneumonia and R.M's other diagnoses of lifelong asthma, it is imperative that the nursing care plan of ineffective airway clearance be carried out. The first goal of this care plan was to have the patient breathe deeply and cough to remove secretions. It is important that the nurse help the patient deep breathe in an upright position; this is the best position for chest expansion, which promotes expansion and ventilation of all lung fields (Sparks and Taylor, 2011). It is also important the nurse teach the patient an easily performed cough technique and help mobilize the patient with ADL's. This helps the patient learn to cough and clear their airways without fatigue (Sparks and Taylor, 2011). This goal was partially met by patient R.M. who was able to deep breath and cough producing a little yellow tinged sputum. The second goal of this care plan is that the patient will have normal breath sounds within 24 hours. The nurse can help this by performing bronchial hygiene as ordered including suctioning and percussion. This enhances the clearance of secretions from airways (Spark and Taylor, 2011). Also, to help the patient have normal breath sounds the nurse should turn the patient every two hours for maximal aeration of lung fields and mobilization of secretions. This repositioning of the patient prevents pooling and stasis of respiratory secretions (Sparks and Taylor, 2011). R.M. was able to meet this goal; he had clear lung sounds to auscultation by the end of the shift on 2/12/14. The final goal of this care plan is for the patient to express feeling of comfort in maintaining air exchange and increased knowledge by discharge. This nurse can implement this goal by teaching the patient relaxation techniques, which reduce oxygen demand, as well as assessing the patients learning needs and providing appropriate information to the patient about reducing their oxygen demands to help...

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