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Scenario: M.W. is a 65-year-old female. She is a retired auto worker who lives in a...

Scenario: M.W. is a 65-year-old female. She is a retired auto worker who lives in a condo with her golden retriever, Charlie. She has a history of diabetes type II diagnosed 3 years ago. She had a myocardial infarction in 2012. She does not exercise. She denies smoking or alcohol use. She was feeling fine until yesterday. A&O x4, shortness of breath on exertion, fine crackles in bilateral lower lobes, O2saturation 89% on RA. S1and S2audible without murmur, cap refill >2 secs lower extremities, <2 secs in upper extremities. Vitals: BP 100/60, HR 84, RR 28, Temp 36.1C. Ht: 5’ 5” Wt: 200 lbs.

Question: What nursing diagnoses are most appropriate for M.W.? Name 3.

(P.S. please have answer be in depth).

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Answer #1

Some of the most appropriate nursing diagnosis for M.V are

  • Ineffective breathing pattern related to pulmonary edema as evidenced by shortness of breath,crackles on both lower lobe,respiratory rate

Or

  • Impaired gas exchange related to pulmonary complications as evidenced by decrease in oxygen saturation
    • Goal:to maintain normal breathing pattern
    • Nursing intervention and rationale
      • Provide semi fowlers or Fowler's position to improve breathing by increasing lung capacity
      • monitor vital signs is the baselin to plan for care
      • Administer oxygen to relieve hypoxia
      • Administer medication which aides in breathing
  • Ineffective tissue perfusion or decrease in cardiac output related to poor pumping of blood from heart or decreased fluid volume as evidenced by hypotension
    • Goal:to maintain normal blood pressure
    • Nursing intervention and rationale
      • Monitor blood pressure, gives baseline information to provide care
      • Place the patient in trendlenburg position to improve circulation to heart by gravitational force
      • Administer IV fluid to increase the blood pressure
      • Provide salt rich diet/salt capsules as per order to increase the blood pressure
      • Avoid unnecessary extra drawing of blood for investigation
      • Monitor strict intake and output chart to assess any fluid loss or excess
  • Imbalanced nutrition more than the body requirement related to overweight /obesity as evidenced by weight (care to be continued after discharge also)
    • Goal:to maintain a healthy weight
    • Nursing intervention and rationale
      • Monitor the patient weight daily
      • Provide a diet plan which helps to maintain healthy weight
      • Encourage the patient to avoid unhealthy food
      • Teach simple exercises which are heart friendly and helps to reduce weight
      • Encourage for a regular follow up
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