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 a...
... middle of paper ...
... sure to let staff know and that R.M. wanted it ordered with each food tray. The patient also ate the majority of his lunch with little need to urge to have more bites by staff.
References
Jarvis, C. (2008). Physical examination and health assessment (5th ed.) with skills DVD. St. Louis: Saunders.
Lemon, P. & Burke, K. (2011). Medical-surgical nursing (5th ed.). New Jersey: Prentice Hall.
Porth, C. (2009). Pathophysiology: Concepts of Altered Health States (8th ed.). Philadelphia: Lippincott, Williams & Wilkins.
Spark Ralph, S. & Taylor, C. M. (2011). Nursing diagnosis reference manual (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
The Cumulative Index to Nursing and Allied Health Literature (CINAHL) was used to find peer-reviewed articles, using query terms such as: aspiration pneumonia, ventilator, and prevention. In addition, the TWUniversal search engine was utilized to find peer-reviewed articles, with the key words: aspiration pneumonia, ventilator, and enteral.
Porth, C. (2005). Pathophysiology: concepts of altered health states (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
Ignatavicius, D. D., & Workman, M. L. (2013). Care of Intraoperative Patients. Medical-surgical nursing: patient-centered collaborative care (7th ed.). St. Louis: Elsevier.
The philosophy and science of nursing. Little Brown, Boston. Watson, J. (1985) The 'Standard' of the 'Standard'. Nursing: Human Science and Humanities.
Practice. In P. A. Potter, & A. G. (7th ed.) Perry, Fundamentals of Nursing (pp. 215-324). Saint Louis MO: Mosby-Elsevier.
Polit, D. F., & Beck, C. T. (2010). Essentials of Nursing Research (7th ed): Lippincott, Williams & Wilkins.
St. Louis, MO: Elsevier Ackley, B.J., Ladwig, G.B., & Flynn Makic, M. (2017). Nursing diagnosis handbook (11th ed.). St. Louis, MO: Elsevier University.
Thorne, S. (2010). Theoretical Foundation of Nursing Practice. In P.A, Potter, A.G. Perry, J.C, Ross-Kerr, & M.J. Wood (Eds.). Canadian fundamentals of nursing (Revised 4th ed.). (pp.63-73). Toronto, ON: Elsevier.
art and science of nursing care (6th ed). Philadelphia, PA, Lippincott Williams & Wilkins, a Wolter Kluwer business.
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Uhland, Vicky. “The Picture of Health.” Momentum 6.3 (2013): 42-45. Academic Search Premier. Web. 20 Mar. 2014.
Gordon, M. (2007). Manual of nursing diagnosis: including all diagnostic categories approved by the North American Nursing Diagnosis Association (11th ed.). Sudbury, Massachusetts: Jones and Bartlett.
The purpose of this post is to analyze the data submitted in this template. I will focus on
Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (Seventh ed.). St. Louis, Mo.: Mosby Elsevier.
Crisp, J., & Taylor, C. ( 2005 ). Fundamentals of Nursing ( 2nd ed. ). Australia: Vaughn Curtis.