Question

Mai Nguyen, Nam's 76 year old mother, has been complaining of fatigue and a persistent cough for approximately 2 weeks. Nam scheduled an appointment for his mother at the family clinic. Mai appears disheveled. Her clothes are mismatched and rumpled, and her hair is tousled. Normally she appears at the clinic dressed as though she were going out for the evening. She had a hard time signing in at the desk and tells the receptionist she has a 1:00 pm appointment, but it is 9:00 am. Mai’s vital signs are as follows: BP, 142/90 mm Hg; pulse, 94 bpm and regular; respirations, 24 and labored; temperature 99.6 F oral.

What additional assessment data would be useful to gather at this time?

During her visit at the clinic, you notice that Mai is extremely confused. Her weight has dropped 7 pounds since her visit last month, her mucous membranes are dry, and she is quite dyspneic with any activity. Mai is diagnosed with pneumonia. Because of her rapid decline, she is admitted to the hospital to receive antibiotics administered intravenously. At the hospital, her initial pulse oximetry reading is 90%, and she is unable to cough up secretions.

What are three appropriate nursing diagnoses to focus interventions for Mai? What actions should you anticipate taking?

After four days in the hospital, Mai is discharged to home. She asks the hospital nurse, “What can I do to make sure I never get that sick again?”
How would you answer this question?

Answer 1

Additional assessment data to be gathered from Mai are

• Her level of behavior
• Orientation to the surrounding environment.
• Intellectual capability
• Communication level
• Social roles and participation
• Functional ability
• Diet pattern
• Sleeping pattern.

Nursing Actions

Nursing Diagnosis	Interventions
Altered level of consciousness related to increased age as evidenced by disorientation,confusion.	Ensure patient safety, make presence of family members, orient to the surrounding environment.
Ineffective airway clearance related to decreased energy as evidenced by ineffective cough, dyspnea.	Maintain Fowler's position, educate deep breathing and coughing exercise, do chest percussion, maintain hydration status, administer mucolytics.
Risk for falls related to decreased sensory perception as evidenced by dizziness, confusion.	Provide safety precautions by placing needed objects closer to her. Remove harm objects away from patient's bed. Orient to the surroundings and minimize the activities.

Discharge Advice

• Advice to continue medication and follow up of care regularly.
• Explain about functional limitations to avoid injury.
• Advice to take plenty of fluids to maintain hydration status.
• Provide plan for daily activities to minimize the risk of falls.
• Encourage deep breathing and coughing exercise to expel the sputum production.
• Involve in social activities to improve the cognition level.
• Provide diet chart to improve nutritional status.