Question

NR226 Fundamentals: Patient Care 1 NR226 Nursing Process Practice Patient Name: Instructions Complete the following after reading (and interpreting) the client data below. Part 1: Due Week 1 Day 2 at Start of Class Underline SUBJECTIVE DATA in blue ink (2 points) (2 points) Underline OBJECTIVE DATA in red ink Part 2: Due Sunday per Course Calendar Identify and list 8 patient problems Write 3 nursing diagnoses (include 3-parts for each diagnosis). Nursing diagnoses must be from approved NANDA 2018-2020 list. Prioritize and number nursing diagnoses (2 points) (3 points) (1 point) Total 10 points Client Data 78 y/o M admitted with cellulitis LLE (due to spider bite) Past medical history C-diff, DM, falls, s/p left hip fracture (January 2017) w/ORIF, Stage II pressure ulcer on coccyx, pneumonia, UTI Assessment BP136/78, HR 91, RR 20, Temp 39.0C A&Ox3, PERLA. Crackles BLL, diminished BUL; Pt has persistent cough and frequent SOB at rest. Cough produces thick yellow sputum at times. S1 S2 present without murmurs, HR Regular, no edema, pulses +3 bilateral radial and pedal. Bowel sounds hypoactive x4. Stage II wound measures 3x2cm with small amount of purulent drainage. Pt states that he has an ill wife at home and none of his children live around the area. Pt verbalizes feeling lonely and does not want to eat much d/t SOB and feeling depressed, Pt constantly uses call light. Orders VS q 8 hr. O2 @ 2L NC; nebulizer treatments q 6 hr; Cefoxitin 1g IVPB q 6 hr. Diet:1800 calorie ADA. Activity: Up with assistance; keep LLE elevated. Labs: CBC, CMP; Send culture of coccyx wound. Wound care: wet-to-dry dressing change on coccyx bid & PRN drainage.

Answer 1

Subjective Data - The subjective feeling and expression of the patient about himself. Here " Patient states that he has an ill wife at home and none of his children live around the area. Pt verbalizes feeling lonely and does not want to eat much d/t SOB and feeling depressed " This part is Subjecitnve data.

Objective Data

The remaining patient data other than the above mentioned and quoted is objective data.

Prioritized Nursing Diagnosis

1, Dyspnea related to respiratory tract infection evidenced by shortness of breath

2, Hyperthermia.related to infection evidenced by an increase in body temperature

3, Hopelessness related to lack of adequate coping mechanism evidenced by lack of self-esteem

Patient problems

1. dyspnea

2, Fever

3 persistent cough

4 Decreased intestinal activity

5. Irregular bowel sounds

6 purulent drainage and probable pain at the wound site

7 anxiety about family

8,hopelessness and lack of selfesteem