Question

P{lease help

Patient with

Patient came to hospital for septic with bacteremia/bacterial infection due to Bacterial infection due to proteus and providencia bacteremia

Patient: 88-yo male, limited code
Allergy: Adhesive bandage

CC: Bacterial infection due to proteus and providencia bacteremia
Hx: CAD, AS, Afib, COPD/emphysema, history of group B strep bacteria x3, CHF

He has bacteremia/bacterial infection due to proteus mirabilis. sepsis/diastolic heart failure/ A-fib/acute hypoxemia respiratory failure/normocytic anemia

Base on this patient please answer these question below

Please give three Nursing Diagnosis for this patient. Please answer

I. Nursing Diagnosis 1

1. Nursing Diagnosis:

Infection

R/t:

AEB:

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. evaluation

II. I. Nursing Diagnosis 2

Risk for impaired gaseous exchange

R/t:

AEB:

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Evaluation

III. I. Nursing Diagnosis 3

1. Nursing Diagnosis

Ineffective airway clearance

R/t:

AEB:

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Evaluation

IIII. I. Nursing Diagnosis 4

Risk for fall

R/t:

AEB:

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Evaluation

V. Pathophysiology- Few sentences described within nursing and medical diagnosis

Answer 1

Nursing Diagnosis	Goals/ Expected Outcomes	Nursing Interventions	Evaluation
Infection related to Pathogens as evidenced by hyperthermia or positive culture results.	Patient will be free from signs and symptoms of infection and culture results will be negative for infected pathogens.	Assess the vital signs Assess the possible source of infection. Perform frequent hand washing, before, during, after patient care and when ever necessary. Use sterile techniques while doing invasive procedures. Administer Iv antibiotics as ordered.	Patient will be showing signs of recovery from infection after 8 hours of proper nursing interventions.
Risk For Impaired Gas Exchange related to infection and decreased oxygen supply as evidenced by acute hypoxemia and respiratory failure.	Patient will be relieved from dyspnea and cyanosis Patients blood gas analysis will be in normal range.	Assess the respiratory rate, depth and pattern. Assess skin color, nails, lips and buccal mucosa for cyanosis. Obtain arterial blood gas analysis and pulse oxymetry. Provide supplemental oxygen therapy. Provide comfortable position and encourage deep breathing exercise.	Patient will be free from distress. Patient will be maintaining good oxygen saturation. Patient will have no cyanosis and ABg values will be in normal limits.
Ineffective airway clearance related to increased mucus production due to infection as evidenced by increased production of secretions and difficulty in breathing.	Patient will maintain a patent airway patients respiratory sounds and rate will be normal.	Assess the respiratory sound, rate, pattern and effort. Assess pulmonary secretion for consistency, color and odor. Encourage to do deep breathing and coughing exercise. Provide chest physiotherapy. Provide comfortable position by elevate the head of the bed or let the patient lean on an over bed table or sit on edge of the bed with arms rest on the over bed table. Provide warm fluids in the diet to facilitate movement of thick mucus secretion.	Patient will be free from mucus secretions Patient will maintain a normal breathing pattern.
Risk for fall related to old age as evidenced by weak in appearance	Patient will be free from risk of fall and demonstrate proper use of preventive measures.	Assess the physical ability, mental status, age related loss of sensory perception, balance and gait. Assess the environmental factors like slippery floor, inadequate light, scattered rugs and objects on the floor and avoid them from patient area. Provide sign board and identification band for risk for fall. Orient the patient to the new unfamiliar hospital environment. Assist with daily activities and instruct the patient to call for help if needed. Set the bed at lowest position and use side rails while sleeping. Encourage the use of devices for assistance.	patient will be free from falls and show behavior that prevent falls like proper use of assisting devices.