In a 78 year old smoker with streptococcal pneumonia and difficulty in coughing out secretions, the nursing d… - GMCH - 2016

GMCH - 2016

Medical & Surgical Nursing

Medium

Appeared in: GMCH - 2016

Explanation

The diagnosis 'Ineffective airway clearance' is a formal NANDA-I nursing diagnosis that describes the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
This diagnosis accurately reflects the patient's primary problem presented in the scenario: 'difficulty in coughing out secretions'.
The phrase 'related to effects of pneumonia' correctly identifies the etiology (cause) of the airway clearance problem, which is the inflammation and increased mucus production from the infection.

Option A: This is a medical diagnosis. It identifies the disease process itself but does not describe the patient's specific response that requires nursing intervention.
Option B: This is a descriptive statement that combines the patient's condition with a potential treatment (chest physiotherapy). It does not follow the structured format of a nursing diagnosis.
Option C: 'Acute Chest Infection' is a general medical term. While the patient may have muscle weakness, this option is not a standardized NANDA-I nursing diagnosis and is less precise than 'ineffective airway clearance'.

Clinical Relevance

Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Formulating a Nursing Diagnosis for Respiratory Impairment in acute care settings.
Prioritizing airway clearance is a critical nursing responsibility in patients with pneumonia. Retained secretions can lead to severe complications, including atelectasis (lung collapse), worsening infection, hypoxemia, and respiratory failure.
Nurses directly impact patient outcomes by implementing interventions like positioning, hydration, encouraging coughing, and performing chest physiotherapy to manage airway clearance.
What if? If the patient had a strong, productive cough but was showing signs of hypoxia (e.g., low SpO2, cyanosis, confusion), the priority nursing diagnosis would likely shift to 'Impaired Gas Exchange' related to alveolar inflammation and fluid accumulation.

How to Approach the Question

First, identify the core task: The question asks for a 'nursing diagnosis', which has a specific structure and purpose.
Analyze the patient scenario to find the primary problem that a nurse can address. Here, it's the 'difficulty in coughing out secretions'.
Recall the standard format for a nursing diagnosis: [Problem] related to [Etiology/Cause].
Evaluate each option. Ask yourself: 'Is this a formal nursing diagnosis, or is it a medical diagnosis, a symptom, or just a description?'
Eliminate Option A because it's a medical diagnosis. Eliminate Options B and C because they are descriptive phrases, not structured nursing diagnoses.
Confirm that Option D correctly identifies the patient's problem ('Ineffective airway clearance') and its cause ('effects of pneumonia') in the standard format.

Concept Tested & Keywords

Concept Tested: Formulating a Nursing Diagnosis for Respiratory Impairment
Stem keywords: 78 year old, smoker, streptococcal pneumonia, difficulty in coughing, secretions, nursing diagnosis
Lead-in keywords: nursing diagnosis
Clinical cues: 78 year old: Age-related changes can weaken cough reflex and respiratory muscles.
Clinical cues: Smoker: Chronic smoking damages cilia, which are responsible for clearing mucus from the airways.

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E6 Nursing Fundamentals Taylor pp. 722-724, 721-723

E6 Medicine Davidson Principles Practice 24e p. 602-604