Nursing Diagnoses: Definitions and classification

Running head: NURSING DIAGNOSIS: A CASE STUDY
Nursing Diagnosis: A case study
Name of the Student:
Name of the University:
Author Note:

NURSING DIAGNOSIS: A CASE STUDY
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INTRODUCTION
Based on the case study provided, Mr X, a 72-year-old male,
experienced a critical aggravation of Chronic Obstructive Pulmonary
Disease (COPD), after which he was immediately admitted to the
emergency ward of a metropolitan hospital in the neighbourhood. The
exacerbating symptoms observed were prolific coughs with enormous
amounts of sputum, increased body temperature of 39°C and dyspnea or
shortness of breath. Tests revealed a community-acquired bilateral lower
lobe pneumonia and that the symptoms were a result of an acute
exacerbation of COPD, which as diagnosed about 5 years back.
Subsequently, he was transferred to the respiratory ward of the hospital
for the treatment. His medical history discloses that he suffered a
myocardial infarction about three years ago, accompanied by a stent
insertion and that he was a chain smoker around 10 years back. He also
depicts hypercholesterolemia. At present, Mr X responds positively to all
the instructions given and is well-oriented to person, place and time.
However, his review reports state that he is unable to reply in complete
sentences, lethargic and shows signs of fatigue. This paper discusses two
of the nursing diagnoses, ineffective airway clearance and activity
intolerance and the assessment, diagnosis, planning, implementation,
evaluation, discharge planning and legal issues associated with each of
these diagnoses (Toney-Butler & Thayer, 2020). Ineffective airway
clearance is the lack of ability to clear air passages of coughs or other
secretions causing difficulties in breathing (Baird
et al., 2016). Activity
intolerance is caused by difficulties in breathing which results in a
disproportion between the demand and supply of oxygen as is often
manifested as a weakness (Cox
et al., 2018). The patient will be referred
to as Mr X throughout the paper to maintain the confidentiality of the case
which will be further elaborated in the legal and ethical section.
NURSING DIAGNOSIS 1: Ineffective airway clearance
Assessment

NURSING DIAGNOSIS: A CASE STUDY
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The purpose of the assessment is to collect information about the
patient for effective diagnosis (Toney-Butler & Thayer, 2020). Assessment
of ineffective airway clearance requires an observation of the breathing
pattern of the person, notice signs of short breaths and if any particular
sound accompanied by breathing. This gives evidence of any internal
obstruction experienced during breathing (Berman
et al., 2018). The
amount of sputum secretion is also an important indicator as abundant
sputum secretions indicate hindrance in airway passage. Collection of the
sputum sample is also necessary for diagnostic tests (Ntoumenopoulos
et
al., 2018). The rate, rhythm and effort incurred in breathing are also
recorded. The temperature of the patient is also crucial as dyspnea with
high temperature may represent an infection. Presence or absence of
cough is also vital for accurate results.
Diagnosis:
The purpose of diagnosis is to study the observations collected
during assessment and form accurate conclusions (Toney-Butler & Thayer,
2020). Mr X demonstrates severe shortness of breath or dyspnea along
with a body temperature of 39°C. Excessive secretions of sputum along
with productive coughing act cause difficulties in breathing
(Ntoumenopoulos
et al., 2018). These signs demonstrate reasons for
probable ineffective airway clearance.
Planning:
The purpose of planning is to incorporate nursing interventions to
develop a suitable patient-centred plan of treatment (Toney-Butler &
Thayer, 2020). Nursing interventions associated with ineffective airway
clearance involve many therapeutic measures. Promoting chest cavity
expansion by lowering the diaphragm, which helps in mobilising the
secretions (Ntoumenopoulos
et al., 2018). Breathing exercises expand
lungs and small air passages to facilitate coughing. Coughing exercises
helps cilia in the efficient movement of the secretions from the airways
while splinting eases the chest pain (Ntoumenopoulos
et al., 2018).

NURSING DIAGNOSIS: A CASE STUDY
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Maintenance of proper hydration is essential as it increases the fluidity of
secretions which can be easily transported by the cilia. Warm fluids must
be administered for enhanced results (Berman
et al., 2018). Respiratory
aids such as nebulisers, percussions and incentive spirometries can also
be used. Nebulisers enhance the fluidity of the secretions and facilitate
easy removal (Chang
et al., 2015). Chest percussions are useful in cases
where coughing or suction are not adequate to remove the cough.
Incentive spirometry helps in deep breaths (Miller, Owens, & Silverman,
2015). Timely administration of the medicines such as mucolytics,
analgesics, expectorants and bronchodilators as prescribed by the
physician is also essential (Yang
et al., 2017).
Implementation:
The purpose of implementation is to describe how the nursing
interventions described above would be executed into practice (Toney-
Butler & Thayer, 2020). Changing the positions of Mr X regularly and
raising the head of his bed promotes the expansion of the chest cavity.
The nurse must also train and help him with different breathing exercises
while demonstrating splinting and productive coughing (Troosters & Bott,
2019). For appropriate hydration, liquids should be provided to the patient
while keeping a check on oedema (Berman
et al., 2018). Additional
respiratory tools must consent with the doctor based on the patient’s
progress before the patient can access it. The nurse must ensure that Mr
X receives the prescribed dosage of medicines (Yang
et al., 2017).
Evaluation:
The purpose of the evaluation is to assess the success of the
nursing interventions by evaluating the patient’s response to the plan
(Toney-Butler & Thayer, 2020). The presence of breathing sounds is
tested. According to the case study, assessment of respiratory rate and
body temperature results that Mr X shows a decrease in the body
temperature from 39°C to 37°C and the respiratory rate from 25bpm to