The nurse assessment of a patient with lung cancer reveals the following: copious secretions, dyspnea, and cough. Based on these findings the most appropriate nursing diagnosis is?

1. A

   Impaired gas exchange

2. B

   Ineffective airway clearance

3. C

   Pain

4. D

   Altered tissue perfusion

Appeared in: DHS 2018 shift 1st

Explanation

• The patient's presentation with copious secretions and a cough are the classic, defining characteristics for the nursing diagnosis of Ineffective Airway Clearance.
• This diagnosis specifically addresses the inability to clear the respiratory tract, which is the direct cause of the patient's symptoms.
• Dyspnea, in this context, is a consequence of the airway being obstructed by secretions, rather than a primary gas exchange problem.
• The focus of nursing care should be on interventions to help clear the airway, such as positioning, hydration, and encouraging effective coughing.

Why Other Options Were Wrong

• Option A: This diagnosis focuses on the exchange of gases at the alveolar level. The patient's primary signs (secretions, cough) point to an obstruction problem, not a gas exchange problem, although one can lead to the other.
• Option C: There is no data in the assessment (e.g., patient report of pain, grimacing, guarding) to support a diagnosis of pain.
• Option D: This diagnosis relates to inadequate circulation and oxygen delivery to tissues. The assessment findings are respiratory, not circulatory.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Selection of the appropriate nursing diagnosis based on respiratory assessment findings to guide bedside assessment, documentation, and the next nursing action.
• For patients with lung cancer or other chronic respiratory diseases, maintaining a patent airway is a top priority to prevent complications such as atelectasis, pneumonia, and respiratory failure.
• Nurses play a crucial role in implementing and teaching airway clearance techniques, including positioning, hydration, controlled coughing, and, if necessary, suctioning.
• What if? If the patient's assessment had revealed wheezing on expiration and use of accessory muscles but no copious secretions, the most appropriate diagnosis might shift to 'Ineffective Breathing Pattern' related to bronchoconstriction.

How to Approach the Question

• First, identify the key assessment findings provided in the clinical scenario: copious secretions, dyspnea, and cough.
• Next, consider the definition of each nursing diagnosis option.
• Analyze which diagnosis most directly aligns with the patient's specific signs and symptoms.
• Recognize that 'copious secretions' and 'cough' are hallmark defining characteristics of a problem with clearing the airway.
• Differentiate this from 'Impaired gas exchange,' which is a problem at the alveolar level, and 'Ineffective breathing pattern,' which relates to the mechanics of inhalation and exhalation.
• Conclude that 'Ineffective airway clearance' is the most precise and primary diagnosis for this set of symptoms.

Concept Tested & Keywords

• Concept Tested: Selection of the appropriate nursing diagnosis based on respiratory assessment findings.
• Stem keywords: lung cancer, copious secretions, dyspnea, cough
• Lead-in keywords: most appropriate nursing diagnosis

Question ID

QDLR5DTC_janZgJoGJTxNB

Copy ID

Reference Book

E6 Nursing Fundamentals Taylor p. 721-723

E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 24-26