Question

Please help to answer these question

Patient with

Patient came to hospital for septic with bacteremia/bacterial infection due to proteus mirabilis.

Patient with history of CAD, AS, Afib on warfarin, COPD/emphysema. History of group B strep bacteria x3, CHF

Base on this patient please answer these question below

Please give three Nursing Diagnosis for this patient. Please answer

Nursing Interventions and Rationale separate

I. Nursing Diagnosis 1

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Rationale

5. Evaluations

II. I. Nursing Diagnosis 2

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Rationale

5. Evaluations

III. I. Nursing Diagnosis 3

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Rationale

5. Evaluations

Answer 1

1.Nursing diagnosis

Infection in blood related to bacterial growth as evidenced by presence of Proteus mirabilis

Goals/ Expected outcomes

To relieve infection from the blood

Nursing intervention

• Administer antibiotics as per order
• Meticulous handwashing, infection control practice, aseptic procedures to be followed
• Monitor the vitals ,GCS or neurological assessment periodically
• Blood investigations, diagnostic as per order

Rationale

• Antibiotics treats infection by killing the bacteria
• This prevents cross contamination and transmission of infection
• In sepsis the body function changes rapidly, to keep a track on it vitals are necessary
• Lab values helps to identify any shock

Evaluation

• The patient is free of infection
• Improved immunity against infections
• No signs of any fever

2.Nursing diagnosis

Risk for impaired gaseous exchange related to infection as evidenced by fluid in the lungs secondary to COPD

Goals/Expected outcomes

• The patient will have normal gaseous exchange

Nursing intervention

• Monitor vital signs
• Administer antibiotics, steroids ,nebulizer as per order
• Provide propped up position
• Teach breathing exercises

Rationale

• Vital signs are the baseline data to get patient status
• Antibiotics treats infection, steroids increases the constricted respiratory pathway, nebulization removes any secretion
• Position will enhance the lung capacity
• Breath exercise like purse lip reduces the pressure on lung and improve gas exchange

Evaluation

The patient is able to do all activities without any difficulty or shortness of breath

3.Nursing Diagnosis

Risk for bleeding related to cardiac issues as evidenced by taking warfarin

Goals/outcomes

The patient will exhibit normal hemostasis

Nursing intervention

• Monitor the patient PT INR values
• Do not prick or do any procedure which leads to incision or injury
• Monitor for signs of bleeding, bruises

Rationale

• The changes in INR values gives the ranges of warfarin in blood
• Any invasive procedure can lead to bleeding for a prolonged time
• The chance of platelet alteration is possible which can lead to bleeding and bruises on skin

Evaluation

The patient has a normal cardiovascular pattern like normal blood pressure, heart rate.