Question

Abdo, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago.

The patient smoked cigarettes one pack per day for 55 years and quit 3 years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are as follows: blood pressure, 90/50 mm Hg; heart rate, 101 bpm; respiratory rate, 28 breaths/min; and temperature, 101.5°F. The pulse oximeter on room air is 85%. The CBC is as follows: WBC, 12,500; platelets, 350,000; HCT, 30%; and Hgb, 10 g/dL. ABGs on room air are: pH, 7.30; PaO2, 55; PaCO2, 50; and HCO3, 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum.

Questions:

3. What nursing diagnoses should the nurse formulate for the patient?

Answer 1

The patient has history paraseptal emphysema, smoking and currently diagnosed with acute community-acquired pneumonia. His respiratory rate is higher than normal and lung sounds are diminished and the physical examination indicate that he is in severe respiratory distress.

The priority nursing diagnosis include

1. Impaired gas exchange related to hypoventilation as evidenced by dyspnea and cyanosis.

2. Ineffective airway clearance related to consolidation of lungs as evidenced by decreased breath sounds over affected lung areas.

3. Ineffective breathing pattern related to decreased lung expansion as evidenced by use of accessory muscles.

4. Risk for spread of Infection related to presence of existing infection.

5. Activity intolerance related to exhaustion associated with dyspnea as evidenced by verbalization of fatigue and weakness.