Problem Statement for COPD CRT
Review: To state the patient's problem is to make a "diagnosis". However, as mentioned earlier (see "Dissecting the Nursing Care Plan") this site attempts to teach a logical, unadorned and free-style manner of recognizing patients' problems and putting them in an appropriate priority. The hope is that, armed with this reasoning, the nurse can turn to Nursing Diagnoses: Definitions and Classification from NANDA-International and select the appropriate "research-based and standardized" diagnosis. For the purposes of simplification, problem statements such as those written for Mr. Culver acknowledges each of Maslow's hierarchical basic human needs and lists them as either "Impaired" or "Threatened" (a.k.a. "at risk for..."). All problem statements are articulated in NANDA-I syntax. There is no precise rule for how causality ("RT") and evidence ("AEB") should be described, both are the nurses' (or students') best expression of the underlying pathological processes and a summary of the most important symptomatology. In other word, the major rule of problem statements is that they make sense to those who write them and read them.
Problem Statement #1: Impaired oxygenation RT chronic alveolar hypoventilation and V/Q mismatch AEB hypercarbia, hypercapnea and refractory hypoxemia.
Since oxygen is the most basic substrate for life, it is naturally listed first. Mr. Culver's disease directly disrupts the transport of adequate amounts of oxygen from the atmosphere to his tissues, oxygenation is truly "impaired". As described in the explanation of COPD Pathophysiology, chronic and continuous airway destruction by smoking has produced a cascading pathology that results in air trapping and reductions in air exchange in the deepest parts of the lung. This is by definition, alveolar hypoventilation. In addition, Mr. Culver has an acute process going on in his bases that causes capillary perfusion in excess of alveolar ventilation... (in this case, pneumonia) causing refractory hypoxemia. The sine qua non of alveolar hyperventilation is CO2 retention, resulting in compensatory build up of serum bicarbonate buffers over time. Again, it is necessary for the nurse (or student) to articulate causality and evidence in the best language and understanding they have, while seeking to learn more about the pathophysiology and clinical presentation of disease states. In this deliberately simplified method, there are few absolute "right" and "wrong" diagnoses... only better and best.
Problem Statement #2: Risk for decreased cardiac perfusion (and/or oxygenation) RT pulmonary hypertension AEB PAC's, EKG findings, and prominent pulmonary arteries on CXR.
As explained in the Pathophysiology of COPD, a common complication of the disease is pulmonary hypertension and consequent right sided heart failure (cor pulmonale). This is the simplest way to state the problem and cause, and the evidence listed confirms the most common symptoms of this condition, all of which are being manifested by Mr. Culver. Symptoms indicate problems with the myocardium, but there is no current evidence of ischemia. Thus this is a problem for which the patient is "at risk."
Problem Statement #3: Risk for impaired nutrition RT steroid associated gastritis and extreme dyspnea AEB "food too much work", "stomach roiled", and thin, wasted body habitus.
This problem statement is in the correct priority following oxygenation. Mr. Culver, however, may have exceeded "risk for" and may actually have "impaired" nutrition. The nurse may upgrade the urgency of this diagnosis when more information is available (like, knowing his actual BMI, his magnesium and phophate levels, observing him eat and noticing how much food is left after his meals.). The nurse has done some informed guessing about the source of Mr. Culver's "roiled stomach" since he is on chronic prednisone and this drug commonly cause GI distress. In addition, the patient has provided the important information about causality in explaining that eating wears him out. For evidence, the nurse principally relies upon the patient's own report and the admission assessment.
Problem Statement #4: Impaired self-esteem RT severe handicap AEB "worthless life".
This is an inferred diagnosis stated in very simplified terms. After the initial interview, and at the beginning of the nurse-patient relationship, Mr. Culver has given the nurse evidence that he is struggling with some higher order need. This diagnosis acknowledges that shared information and speculates about its source. In this sense, it is a "place-holder" diagnosis. When the nurse refines these problem statements with the correct NANDA diagnosis, there may be more evidence that defines and characterizes it with more specificity. ("Despondency, depression, hopelessness, etc.)
Problem Statement #1: Impaired oxygenation RT chronic alveolar hypoventilation and V/Q mismatch AEB hypercarbia, hypercapnea and refractory hypoxemia.
Since oxygen is the most basic substrate for life, it is naturally listed first. Mr. Culver's disease directly disrupts the transport of adequate amounts of oxygen from the atmosphere to his tissues, oxygenation is truly "impaired". As described in the explanation of COPD Pathophysiology, chronic and continuous airway destruction by smoking has produced a cascading pathology that results in air trapping and reductions in air exchange in the deepest parts of the lung. This is by definition, alveolar hypoventilation. In addition, Mr. Culver has an acute process going on in his bases that causes capillary perfusion in excess of alveolar ventilation... (in this case, pneumonia) causing refractory hypoxemia. The sine qua non of alveolar hyperventilation is CO2 retention, resulting in compensatory build up of serum bicarbonate buffers over time. Again, it is necessary for the nurse (or student) to articulate causality and evidence in the best language and understanding they have, while seeking to learn more about the pathophysiology and clinical presentation of disease states. In this deliberately simplified method, there are few absolute "right" and "wrong" diagnoses... only better and best.
Problem Statement #2: Risk for decreased cardiac perfusion (and/or oxygenation) RT pulmonary hypertension AEB PAC's, EKG findings, and prominent pulmonary arteries on CXR.
As explained in the Pathophysiology of COPD, a common complication of the disease is pulmonary hypertension and consequent right sided heart failure (cor pulmonale). This is the simplest way to state the problem and cause, and the evidence listed confirms the most common symptoms of this condition, all of which are being manifested by Mr. Culver. Symptoms indicate problems with the myocardium, but there is no current evidence of ischemia. Thus this is a problem for which the patient is "at risk."
Problem Statement #3: Risk for impaired nutrition RT steroid associated gastritis and extreme dyspnea AEB "food too much work", "stomach roiled", and thin, wasted body habitus.
This problem statement is in the correct priority following oxygenation. Mr. Culver, however, may have exceeded "risk for" and may actually have "impaired" nutrition. The nurse may upgrade the urgency of this diagnosis when more information is available (like, knowing his actual BMI, his magnesium and phophate levels, observing him eat and noticing how much food is left after his meals.). The nurse has done some informed guessing about the source of Mr. Culver's "roiled stomach" since he is on chronic prednisone and this drug commonly cause GI distress. In addition, the patient has provided the important information about causality in explaining that eating wears him out. For evidence, the nurse principally relies upon the patient's own report and the admission assessment.
Problem Statement #4: Impaired self-esteem RT severe handicap AEB "worthless life".
This is an inferred diagnosis stated in very simplified terms. After the initial interview, and at the beginning of the nurse-patient relationship, Mr. Culver has given the nurse evidence that he is struggling with some higher order need. This diagnosis acknowledges that shared information and speculates about its source. In this sense, it is a "place-holder" diagnosis. When the nurse refines these problem statements with the correct NANDA diagnosis, there may be more evidence that defines and characterizes it with more specificity. ("Despondency, depression, hopelessness, etc.)