Question

156 SECTION TWO . Priority Setting and Decision Making As you provide morning care to Mr. Y you assess the following signs and symptoms: 1. Nonproductive cough; long expiratory phase during respiration 2. Increased shortness of breath with mild exertion 3. Crackles audible throughout the bilateral lung fields 4. Anxious and restless o Collaborative Learning Activity: With a partner, do the following: (1) select the one nursing diagnosis that is a priority at this time, (2) provide a rationale for your selection, and (3) list the nursin interventions that assist you to meet the needs of the patient. All of the following nursing diagnoses may apply to Mr. Y: Ineffective breathing pattern, Ineffective airway clearance, Risk for injury, Risk for infection, Anxiety, Impaired gas exchange, Activity intolerance, Risk for impaired skin integrity, Imbalanced nutrition: less than body requirements, Sexual dysfunction Nursing Diagnosis Rationale Nursing Interventions At 12:00 noon the patient care assistant reports that Mr. Y is very warm and that his VS are T 102°F, P 98, R 32, BP 140/84. He is expectorating thick yellow-colored sputum. Based on the situation at 12:00 noon, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing interventions for this situation and identify your follow- up action plan for Mr. Y. NURSING INTERVENTIONS DECISION-MAKING DIAGRAM A. Auscultate lung sounds B. Administer antipyretic if ordered C. Assess orientation and LOC New Action Plan D. Check oxygen saturation level E. Retake VS in 2 hours F. Inform physician NOTES Priority Problem

Answer 1

As you provide morning care to Mr Y you assess the following signs and symptoms

1. Non-productive cough; long expiratory phase during respiration

2. Increased shortness of breath with mild exertion

3. Crackles audible throughout bilateral lung fields

4. Anxious and restless

What will be the nursing diagnosis, its rationale and the interventions?

Nursing Diagnosis	Rationale	Nursing intervention
Acute Bronchitis	Caused due to viral or bacterial infection. Can also be caused by inhalation of infected or harmless chemical or physical agents Shortness of Breath Wheezing Crackling Cough- with yellow or green expectorant	Clear the airway- positioning Elevate the head of the bed at least thirty degrees Assess breathing Patterns Assess breath sounds-auscultation Encourage fluid intake Monitor the vital signs

Part -2

At 12 noon the care assistant reports that Mr Y is very warm and his vital sign are Temp- 102°F, Pulse 98, Respiration-32, BP 140/84. Based on this this situation identify the priority problem, prioritize the nursing intervention and follow-up action plan.

Nursing Interventions

A. Auscultate lung sounds

B. Administer Antipyretic If Ordered

C. Asses orientation ad LOC

D. Check Oxygen Saturation

E. Retake VS I 2 hours

F Inform physician

New Action Plan

#1	#2	#3	#4	#5	#6
B	D	F	C	E	A

Reduce the temp, control BP. Clear airway and breathing

Reduce the temperature, Control The BP, Maintain healthy O2 saturation

Priority Problem