Question

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The patient has bilateral lung transplant a few years ago. He currently a problem with chronic infection of a lung transplant, Fluid volume overload r/t CHF MANIFESTED BY DYSPNEA, edema 2+, Diabetes Mellitus type 2 he has chronic obstructive lung disease, oxygen dependent, atrial fibrillation, hypertension, coronary artery disease, active delirium.

Based on his problem please help to answers these question

7. Nursing Process - Nursing Diagnosis:

Identify 3 physiological nursing diagnosis based on above assessed patient needs and nursing considerations. Develop two nursing diagnoses below. Must have at least one problem addressing patient’s admitting diagnosis.

State rationale for choosing this diagnosis:

8. Nursing Process: Planning and Intervention: Goals and Interventions: Develop one goal and four interventions for each diagnosis. One intervention should include patient education.

Goal (S.M.A.R.T.):

9. Evaluation: Please describe how your patient met/did not meet goal:

10. (Nursing Diagnosis #2)

State rationale for choosing this diagnosis:

Goal (S.M.A.R.T.):

Nursing process: Evaluation: Please describe how your patient met/did not meet goal:

Answer 1

Nursing care plan :

DIAGNOSIS PLANNING NTERVENTION EVALUATION Nursing Diagnosis: Short Tem: Short Term Impaired gas >Within 15 mins of Elevate the head Goal partially met exchanged 2o to ventilation and perfusion breathing will be inequality; related to duty, difficulty of of the bed 45o (semi fowler's) position. It maximize lung Long Term: Pt. was able to thus sustainverbalize in Long Term: open airway After 1 day Pt will Advised the pt to disease and its course keep calm during of treatment ventilation and adequate difficulty to prevent oxygenation within normal limits and having disease aggravation of the >Encouraged deep respiratory distress After 3 days Pt wilexercise. It promotes be able to verbalize factors that would contribute to exacerbation of disease NC as ordered by and will participate in physician. treatment regimen O2 inhalation via

DIAGNOSIS ANNING INTERVENTION EVALUATION Short Tem: >Within 4 hours of Elevate the head >Goal partially met >Difficulty of clearance related to of the bed 45o (semi increase production of liquefy & expectorated & fowler's) position. It tracheobronchial tree as be prevented. cough, crackles, chest Long Tem: breathing was lessened further complication wil maximize lung expansion thus sustain Long Term: Pt. was able to & back pain. to the therapeutic duty, pt will be able to loosen secretions & for regimen. better expectoration. Pt. Was able to >Encouraged to condition, therapy increase fluid intake if management of his and side effect not contraindicated. condition & follow the of med After 3 days Pt will disposal of secretions. be demonstrate behavior to improve adequate lifestyle changes to improve adequate oxygenation & as ordered by attending prevent exacerbation of physician Nebulize with

DIAGNOSIS PLANNING INTERVENTION VALUATION Nursing Diagnosis: Short Term: Short Term >Within 4 hours of >Encouraged to eatGoal met imbalanced less than body requirements related to inadequate intake of nutritious food relieved. to meet metabolic needs secondary to underlying Long Term: disease as evidenced by>After 2 days of duty adequate rest & sleep, it adequate rest & sleep, loss of appetite &body patient wll be duty patient will be adequate nutritious food like green leafy vegetables, fishes and fruits rich in vitamin C to understand having boost immune system proper nutrition and the regained body strength & loss of appetite will be Long Term: Pt. Was able to Advised to haveimportance of having helps to regained body regarding to his health improvement in appetite & proper nutrition. ung (Dibencozide) Heraclene for appetite stimulants as ordered by attendi