Scenario
Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies. On admission, he states that he hasn’t been feeling well for 3-4 days, complained of dyspnea, generalized body pain, fatigue, and a productive cough of yellow colored sputum. He has not slept in 2 nights, is agitated, anxious about his health and reported feeling weak. Mr. Lawson has little appetite and is mostly eating soup even though the doctor ordered a regular diet. He is alert and oriented x 4, continent of bowel and bladder and on bed rest due to weakness and unsteady gait. Physical assessment reveals B/P 168/90; pulse 104; respirations 26; temperature 98.9 F; oxygen saturation 93% on o2 2L via NC with diminished breath sounds bilateral and expiratory wheezing on auscultation. Bowel sounds are present on all four quadrants, heart sounds are regular and his skin is intact. I.V. antibiotics are ordered and started.
Directions: Generate three (3) priority nursing diagnoses based on the scenario. After completing this step, arrange the three (3) priority diagnoses in the order of priority and generate one (1) goal and three (3) outcomes for the most prioritized diagnosis.
Nursing diagnosis
*Impaired gas exchange
*Ineffective airway clearance
*Imbalanced nutritional
1• Ineffective airway clearance related to increased production of secretions as evidenced by productive cough.
Goal: After Nursing intervention patient maintains airway patency.
Outcomes:*After nursing intervention patient can mobilize the secretions by deep breathing and coughing exercise
*wheezing present on auscultation
*Client respiratory rate is within normal limit.
2• Impaired gas exchange related to inflammatory changes in the lungs as evidenced by dyspnea.
Goal: After Nursing intervention patient reduces the symptoms of respiratory distress.
Outcome:* After Nursing intervention patient reduced the symptoms of respiratory distress
*Patient improved ventilation and oxygenation of tissues within tolerable limits.
*Patient maintained normal respiratory pattern
3•Imbalanced nutritional status less than body requirements related to loss of appetite as evidenced by decreased food intake.
Goal: Patient maintains adequate nutritional status.
Outcomes: * Patient maintained adequate nutritional status within tolerable limits.
* Patient reduced fatigue level
*Patient demonstrated increased appetite.
Scenario Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history...
Scenario Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies....
Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed, and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies. On...
Explain how the professional nurse utilizes the nursing process in the nurse-client relationship: Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity...
Mr. S.L is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies. On admission,...
Explain how the professional nurse utilizes the nursing process in the nurse-client relationship: Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity...
Practice Differential Diagnosis Assignment Mr. Eric Parker is a 35 year old African American male, is a regular patient of an urban primary care clinic. His last check up [2 years ago], was normal, including cholesterol of 170 mg/dL. He is married with three school age children and is employed as a division sales representative for a national computer network. In addition, he is an avid runner and fisher man. CC: “My stomach has been aching and burning, off and...
Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment...
Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment...
Brief Patient History Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment...
Mr. A is an 18-year-old 80-kg African American man admitted to the intensive care unit after emergency surgery for gunshot wounds to the abdomen. The surgical procedure was extensive and involved repair of a perforated bowel, splenectomy, and hemostasis. Mr. A’s mean arterial pressure (MAP) dropped below 65 mm Hg during resuscitation, and he received 9 units of packed red blood cells and 4 L of lactated Ringer solution intravenously (IV) to achieve hemodynamic stability. Clinical Assessment Within 24 hours...