Nursing Diagnosis

875 Words Jun 24th, 2018 4 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.
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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 prevent the reoccurrence of obstruction (Sparks and Taylor, 2011).
Nursing Diagnosis II R.M.’s second nursing diagnosis imbalanced nutrition less than body requirements related to lack of nutrition as evidenced by untouched food trays. This care plan is also evidenced by subjective and objective evidence. In R.M.'s patient chart, the previous nurses had noted subjectively that the patient does not touch food trays and objectively that less than 50% of all meals since hospitalization had been consumed. Patient R.M. needs to improve his nutritional intake so that he can provide his body with
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