Question

Thanks for answer all my nursing dianoisi, Please help to answer the last question about

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

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 :1

Infection related to bacteraemia due to proteus and providenci as evidenced by bacteria culture and blood culture.

Goals :

• Patient remain free from sign and symptoms of any infection.
• Demonstrate to the patient ability to perform hygienic measure like oral care and hand washing.

Intervention :

• Assess the skin color , texture and moisture.
• Routine monitor for white blood cells count, serum albumin and serum protein.
• Check patients immunization history.
• Assess the patient temperature every 4 hr.
• Monitor patient sign of swelling.
• Take note patients current medication history like corticosteroids agent.

Evaluation :

• Patient swelling is reduced.
• Patient blood culture shows reduce infection.

NURSING DIAGNOSIS :2

Risk for impaired gaseous exchange related to altered oxygen supply secondary to cardiac or pulmonary disease and presence of infection.

Goals :

• Patient maintain optimal gas exchange as evidenced by usual mental status, baseline heart rate.
• Patient remain free of sign of respiratory distress.

Intervention :

• Position to the patient with head of the bed elevated with 45 degree semifowler position.
• Regular check the patient position.
• Monitor oxygen saturation .
• Encourage the patient for ambulation.
• Avoid high concentration of oxygen in patients with COPD unless orderd .
• Instructions to the patient deep breathing exercise and coughing.
• If needed suction is done.

Evaluation :

• Patient gaseous exchange maintain.
• Respiratory distress not occur.

NURSING DIAGNOSIS :3

Ineffective airway clearance related to bronchospasm and increase production of secretion as evidenced by abnormal breath sound, persistent cough and change the depth and rate of respiration.

Goals :

• Maintain airway patency with breath sound clear .
• Demonstrate behaviour to improve airway clearance i.e.cough effectively.

Intervention :

• Assess and monitor respiration and breathing sound.
• Note presence of dyspnea and respiratory distress.
• Assist patient with comfortable position elevated the head of the bed.
• Administer bronchodialator if needed.

Evaluation :

• Patient breath sound clear .
• persistent cough absent.

NURSING DIAGNOSIS :4

Risk for fall related to older age(88yrs) , altered cerebral function secondary to hypoxia, presence acute illness.

Goals :

• Patient will not sustain fall.
• Patient and caregiver will implement strategy to increase safety and prevent falls in the home.

Intervention :

• For patient at risk for fall provide health care providers to implement fall precautions .
• Move items used by the patient within easy reach.
• Respond to call light as soon as possible.
• See to it that the beds are the lowest possible position.
• Use side rail on bed.
• Avoid use of restraints to avoid falls.

Evaluation :

• Safety precautions maintained for fall by the care provider.

## In case of nursing diagnosis started with risk for have no as evidenced by.

PATHOPHYSIOLOGY :

Infection -- bacteraemia --- sepsis-- severe sepsis-- septic shock.

When inflammatory response is occur via microorganisms like bacteria than bacteria entered blood stream and occur bacteraemia. Serious body wide response occur like fever, weakness, increase white blood cells count than sepsis prone to severe. Sepsis cause decrease blood pressure and occur septic shock.

MEDICAL DIAGNOSIS :

• Blood culture : sample is taken from two different site of the body.
• Urine test: If the doctor suspect a urinary truct infection.
• X ray, CT scan, USG if needed.

NURSING DIAGNOSIS :

• Assess blood pressure, heart rate.
• Monitor temperature and urine output .
• Maintain oxygen saturation .