JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences
Nursing Department

PROBLEM LIST

Name of Patient: Mrs. D___________________ Age: _80____ Sex: Female____

Diagnosis: Respiratory failure secondary to sepsis Attending Physician: ______________

Problem list (Nursing Diagnoses) Rationale

1. Ineffective airway clearance related to Secretions increases due to presence of tube
increased mucus production associated to in the trachea. At the same time, The patient
tube in the trachea as evidenced by thick has respiratory failure secondary to sepsis
yellowish secretions. wherein her infection prompts the body to
fight and as a result, production of yellowish
secretions occurs.
2. Impaired gas exchange related to altered The patient is experiencing respiratory failure
oxygen supply. hence the ability of her lungs to do its
function is decreased hence there is a
possibility that impaired gas exchange to
occur since there is lesser oxygen supply.
3. Risk for decreased cardiac output related Mechanical ventilation causes changes in
to mechanical ventilation. intrapleural or intrathoracic pressure and lung
volume which can affect cardiovascular
functions such as atrial filling or preload; the
impedance to ventricular emptying or
afterload; heart rate and myocardial
contractility ( Shekerdemian, L. & Bohn, D.
1999)
4. Anxiety related inability to breathe without The patient who is connected to both NGT
adequate support. and ETT can be anxious since the patient
might feel that she is now not capable of
supporting herself that even breathing is hard
for her and she needs machines to do this.

5. Risk for infection related to indwelling Urinary catheters can somehow allow
urinary catheter bacteria to enter the body which can later on
cause infection urethra, bladder and kidneys
(NHS,2020).

References:
Shekerdemian. L & Bohn, D. (1999). Cardiovascular effects of mechanical ventilation. Archives
of Disease in Childhood;80:475-480.
Herdman, T., & Kamitsuru, S. (2020). Nursing Diagnoses: Definitions and Classification [Ebook]
(11th ed.). New York: Thiem. Retrieved from
http://www.thieme.com/images/emails/NANDA_Preview.pdf

Risks of a Urinary Catheter - NHS. (2020). Retrieved 15 September 2020, from

https://www.nhs.uk/conditions/urinary-catheters/risks/

Name of Student: Leorenna Nathalia Grace E. Cabalse

Name of Clinical Instructor: Jan Maverick S. Rabino, RN