Question

HISTORY OF PRESENT ILLNESS: Gladys Conn is a 74 year old female that presents to the emergency department. She states "I have been having a hard time breathing for the last two days and it is getting worse. I have been coughing up yellow stuff for a week so I know that means I have an infection. I haven't even had a cigarette today because I am feeling so lousy. PHYSICAL EXAM: Gladys is alert and orientated. Blood pressure 138/86, temperature 98.7, pulse 60, respirations 24. Her skin is pink and it is warm. She is not diaphoretic. Her respirations are slightly labored and she has coarse crackles in her left posterior base, the remainder of her lungs fields are clear. Her oxygen saturation is 90% without oxygen. Her heart rhythm is regular and S1 and S2 are present and no murmur is heard. Document the information from the case study above in a charting format of your choice 1. Date/Time 2. What are two priority nursing diagnoses/nursing problems for this patient? 1 2. 3. What are three nursing interventions that are a priority for this patient? 1. 2. 3. List three health promotion/teaching topics for the respiratory system. 4 1. 2. 3.

Answer 1

74 yrs/ F

C/O Dyspnea with cough and yellow phlegm

H/O cigarette smoking

O/E BP- 138/86

P- 60

R- 24

SO2 - 90%

T - 98..7

Heart - S1, S2 normal

Lung - Coarse crackle in left posterior base

it may be pneumonia or COPD related Bronchiectasis(permanent widen and damage of airways of the lung)

2.  Nursing diagnosis

(a) Sever Dyspnea related to obstructing airway/ineffective airway clearance/damaged airway as evidenced by

1. labored breathing, 2. SO2 90%, 3.  The coarse crackle in left posterior base

(b) Impaired gas exchange related to damaged alveolar wall/ineffective airway clearance/damaged airway as evidenced by

1. so2 90% 2. patient statement of feeling tired.

3. Nursing intervention

• Assess patient respiration, breathing pattern, respiratory sound, oxygen saturation, skin color, and consciousness.
• Give semi fowler position to the patient and provide the extra pillow for comfort, for full lung expansion.
• Give oxygen therapy to the patient to improve oxygen saturation.
• Provide chest physiotherapy for better excretion of sputum and to improve saturation.
• Suction airway to help the patient remove those secretions.

4.

a. Lifestyle modification to prevent respiratory diseases

b. Health effects of smoking

c. Complication of respiratory diseases