Question

MN, age 69 is admitted to the Emergency Department with complaints of tightness and pain upon inspiration, SOBOE, fever of 102, productive cough and fatigue. CBC reveals elevated WBC’s. A respiratory exam reveals decreased breath sounds bilaterally and crackles in the right base posteriorly. MN has not been able to a walk everyday as a result of feeling tired and “coughing all the time.” MN exercises every day to help maintain her weight. MN states the cough keeps her up all night and this also disturbs her husband. Doctor’s orders: D5 ½ NS @ 75 cc/hour CXR Turn cough and deep breathe every 2 hours Incentive spirometry every hour OOB Regular diet Morphine Sulfate 4mg IV q 4 PRN The assessment column of the care plan sheet will assist you to identify the nursing diagnoses and the priority diagnosis. 1. You are assigned to take care of MN. Her vital signs are BP 140/80, P 92, R 22 and T 102. Based on these values, what do you think is going on with MN? (A medical condition/diagnosis is acceptable) 2. Identify 4 Nursing Diagnoses for this patient (Base only) 3. Identify the priority nursing diagnosis for MN. (NANDA base only) 4. What four (4) interventions for your priority diagnosis (independent/interdependent/dependent) might be used to care for this patient? Include rationales with a reference source for each intervention. You may include medications and treatments. It will be assumed the medications and treatments have doctor’s orders. 5. Identify 4 outcomes/goals that you expect for MN as a result of your interventions.

Answer 1

1.Diagnosis - pulmonary Tuberculosis.

Tuberculosis is an Infectious disease usually caused by mycobacterium tuberculosie Bartea Tuberculosis generally affect the lungs, but can also affect Ther parts of the body symptoms are chaonic cough with Blood stairing mucus, fever, night sweats and weight loss

2.Four nursing diagnosis:

• Impaired gas exchange.
• Risk for infection.
• Knowledge deficit.
• Imbalanced nutrition.

Impaired gas Exchange related to the Presence q sisk factors, Redund The Effectiveness of surfau lung, Damage to the alveola capillary membrare Risk for Infection related to & Decreased endwance, decreased idary function, secretion were settled * malnutrition > knowledge deficients: * Interpretation is incorrect, inaccurate * lack & knowledge Icognitive >> Imbalanced Nutrition:- & Frequent coughing sputum Production Existence, & Dyspnoea

3.priority diagnosis (NANDA only)

• Imbalanced nutrition.

Imbolanud Nutaptions * Frequent coughing, sputum production * Euisteru a Dyspnea & Andrenia & Impairment of financial capability

4. Four nursing intervention (independent) and rationale:

③ Assessment and communicate the nutritional status of clients and family Rationales Extent problem and Intervention Assess the client preferred diet and alistikad Rationale - In quased dietary istake monitor Intake and output periodically bol Rational measuring Effectivness of nutrition ent and triels Enwurage and provide frequent sest paiods. Rationale - save Ereigy and occurrence of metabolic fener 6 Enwurage an

5.outcomes;

QDemonstrate progressive weight gais toward goal with noimalization & laboratory values and be free & signs & malnutrition ® Initiate behavious I lifestyle change to regain to maistais appropriate weight 20