Question

Scenario: M.W. is a 65-year-old female. She is a retired auto worker who lives in a condo with her golden retriever, Charlie. She has a history of diabetes type II diagnosed 3 years ago. She had a myocardial infarction in 2012. She does not exercise. She denies smoking or alcohol use. She was feeling fine until yesterday. A&O x4, shortness of breath on exertion, fine crackles in bilateral lower lobes, O₂saturation 89% on RA. S₁and S₂audible without murmur, cap refill >2 secs lower extremities, <2 secs in upper extremities. Vitals: BP 100/60, HR 84, RR 28, Temp 36.1C. Ht: 5’ 5” Wt: 200 lbs.

Question: What nursing diagnosis takes priority and What interventions would you recommend for M.W.’s priority diagnosis? Name 5 and provide rationale for each.

(P.S. please have answer be in depth).

Answer 1

M.W is an old female with a history of type II diabetes, myocardial infarction. Her present complaints of shortness of breath, fine crackles indicate pulmonary edema due to heart failure. The priority nursing diagnosis for this patient is

• Ineffective Breathing pattern related to shortness of breath as evidenced by exertion.
• Ineffective airway clearance related to hypoxia as evidenced by decreased oxygen saturation.
• Ineffective tissue perfusion related to impaired oxygen transport as evidenced by delayed capillary refill in the lower extremities.
• Imbalanced nutrition more than body requirement related to metabolic needs as evidenced by sedentary lifestyles.

Nursing Intervention:

Intervention	Rationale
assess the rate and depth of respiratory rate.	For the early identification of diseases.
Place the patient in rest and comfortable position.	To reduce the oxygen demand.
Educate about deep breathing and coughing exercises.	To clear the airway secretions.
Check the dorsalis pedis and posterior tibial pulses	Absence of pulse indicates arterial insufficiency.
Assess the extremities for edema and elevate the leg.	It improves the venous return.
Monitor oxygen saturation level and administer O2.	To prevent hypoventilation.
Educate the client about the change in lifestyle activities and behaviors.	To improve the efficiency of the client.
Educate about the diabetic diet intake to maintain an appropriate weight.	Maintaining normal weight and balanced diet control diabetes.