Question

Utilizing standard principles of the nursing process, please post four nursing diagnoses in PES format with appropriate nursing assessments, interventions and expected outcomes for the following patient. Feel free to collaborate and comment on each other's postings. What kinds of additional assessments would you need to make?

Mr. Batista is a 55 year-old single machinist who enters the ER C/O SOB with exertion. He denies chest pain but has a productive cough. He smoked 1 PPD for 40 years. He is admitted with a diagnosis of COPD and Community-Acquired pneumonia for the second time in six months. He had a temp of 101.8º on admission. You are the nurse who is caring for him on the medical unit and he is expressing anxiety regarding his ability to work following discharge. His lungs are now clear though he still has a productive cough which he says he has all of the time. He is C/O weakness and has developed the need to take frequent breaks while walking on the unit. He is 6 feet tall and weighs 150 lbs.

Answer 1

1. Ineffective airway clearance related to increased production of cough as evidenced by productive cough.

Nursing Assessment

• Assess respiratory status of the client including rate, breath sound (wheezes, crackles, ronchi), cough (productive or non productive )
• Note presence of dyspnea as for reports anxiety, distress and use of accessory muscle.

Nursing intervention

• Position :semi fowler position elevate head end of bed.
• Assistant with measures to improve the effectiveness of cough
• Administer nebulization as needed.
• Demonstrate effective deep breathing coughing exercise
• Suction as needed
• Administer bronchodialator and expectorant as prescribed by the physician.

Expected outcome :Maintain airway patency and gets relief from cough.

2. Activity intolerance related to weakness and imbalance between oxygen supply and demand.

Nursing Assessment

• Assess the activity level of the patient to get baseline data.
• Assess the respiratory status. Respiratory distress may be cause of weakness.
• Assess the nutritional status to identify energy reserve which is needed during activity.

Nursing intervention

• Assist with activity of daily living.
• Provide emotional support and positive attitude regarding abilities
• Teach energy conservation technique such as resting for at least 1 hour after meal before starting a new activity.
• Deep breathing exercise three or more times daily.
• Encourage the physical activity.
• Encourage verbalization of activity.

Expected outcome

• Patient will exhibit tolerance during physical activity.

3.Risk for infection community acquired pneumonia related to smoking

Nursing assessment

• Assess the signs and symptoms of infection.
• Assess the factors aggravate infection

Nursing intervention

• Instruct regarding risk factor of infection( CAP) such smoking, alcoholism, overcrowding
• Advice the patient to avoid smoking.
• Teach the adverse effect of smoking
• Arrange to attend stop-smoking group or follow self help group
• Avoid situation where strong urge to smoke.

Expected outcome

• Patient will eliminate the habit of smoking and gets free from infection.

4.Risk for developing non communicable disease related to deficient knowledge of aggravating factors such as smoking and obesity

Nursing assessment

• Assess body mass index to get base line data.
• Assess the knowledge level of patient.
• Assess motivation level to learn.

Nursing intervention

• Provide instruction regarding the adverse effect of smoking
• Teach patient regarding the prevention of developing non communicable disease.
• Demonstrate effective physical exercise to reduce weight.
• Teach patient about diet which nutritious and reduces weight.

Expected outcome

• Patient will explain the importance of cessation of smoking and prevention of developing NCD