Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders
and Rationale
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Subjective:
Daughter reported patient exhibited “mood swings” and
periods of “confusion.” Client expressed
she didn’t want to move “anymore than she has to.”
Hx of DM II, CAD
Objective:
Temp: 101.0
Basilar rales bilaterally
Elevated BP (145/86)
Elevated HR (110)
Client is in atrial fibrillation w/ rapid ventricular response
EKG findings of inferior infarction and left axis deviation
Decreased urine output (0 ml/10 hours)
Elevated potassium level of 5.3
Elevated BUN (41)
Elevated Creatinine (1.73)
2x3, 1 inch depth stage II ulceration on coccyx
Unstageable ulceration on right heal
Presence of multiple tears on upper extremities
Client is NPO
Elevated blood glucose (185)
Yellow sputum production
Post-CVA
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Problem
Impaired gas exchange
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Long Term:
Client will demonstrate improved ventilation and adequate
oxygenation as evidenced by blood gas levels within normal parameters for this client
by 09:00, [date].
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-Assess nutritional status
including serum albumin level and body mass index. Weight loss in a client with
COPD ha a negative effect on the course of the disease; resulting in a loss of muscle
mass and in the respiratory muscles which can lead to respiratory failure
(Celli & MacNee, 2004, pg).
-Help the client eat small
frequent meals and use dietary supplements as necessary.
Having a BMI less than 21 has been associated with earlier mortality in patients
with COPD (Schols et. al, 1995)
-monitor patient’s blood gas levels
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R/T
Alveolar-capillary membrane changes, ventilation-perfusion imbalance
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Short Term:
Client will maintain clear lung fields and remain free
of signs of respiratory distress by 12:30, today.
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-Monitor respiratory rate, depth and effort.
-Monitor client’s behavior and mental status for the onset
of restlessness. Changes in a client’s
mental status can be an early sign of impaired gas exchange
(Simmons & Simmons, 2004).
-Monitor client’s oxygen saturation continuously by pulse
oximetry. The goal of inpatient therapy
for the client with COPD is to maintain the oxygen saturation greater than 90% and
PaO2 at or above 80 mm Hg to maintain cellular oxygen
(Celli & MacNee, 2004)
-Position client in the semi-Fowler’s position. Research indicates that the 45 degree position
facilitates breathing and reduces the risk of pneumonia (Speelberg & Van Beers, 2003).
-Remind the client to
breathe through his nose and not his mouth
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AEB:
Altered BP outside of acceptable parameters, oliguria
(0 ml/10 hr), dysrhythmias, altered respiratory rate (24), decreased Hgb (10.2),
decreased albumin (2.0), bilateral lobar rales, 90% oxygenation status on room air
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