Question

Mai Nguyen, Nam’s 76-year-old mother, has been complaining she feels tired all the time, as though she just can’t do what she normally does. She describes having a hard time catching her breath as she walks up stairs and goes about her day. Nam has noticed that his mother’s ankles are more swollen than he has ever seen them. He schedules an appointment for his mother at the family clinic where you are the nurse. Mrs. Nguyen appears pale and not her usual energetic self. Nam tells you that his mom is “not right” and seems to be confused about things at home, which is not like her. She has a history of chronic congestive heart failure.

During her visit at the clinic, you observe that Mai has a cough. She spits a small amount of pink, frothy mucus into a tissue. Mrs. Nguyen’s vital signs are as follows: BP, 142/90 mm Hg; pulse, 96 beats/min and with some irregular beats; respirations, 38 breaths/min and shallow; temperature, 97.8°F (36.5°C) oral.

You decide to include a nursing diagnosis of Acute Confusion in Mrs. Nguyen’s plan of care.

1. What symptoms does she have that support this nursing diagnosis?

2. What physiological changes are causing these symptoms?

Answer 1

Symptoms of acute confusion include swelling of any part of body such as arms and legs, shortness of breath, fatigue, confusion.This symptoms are seen in mai Nguyen so acute confusion supports the nursing diagnosis.

2)The chronic congestive heart failure is the cause of these symptoms.