Question

It is 8:10 am right after a group of nursing started their sheet and the are admitting a Mr. Jones to the hospital from the emergency department (ED) with shortness of breath, weakness, and recent weight loss. Mr. Jones has a history of COPD and lung cancer. He has not been eating well, and has lost 18 lbs in the past 4 months. Mr. Jones mobility has been affected not only by his weakness, but also by his worsening shortness of breath. Because of this, Mr. jones has been bed bound for the past few weeks. He also developed a stage 2 pressure ulcer. Mr. Jones is on 2L of O2 per nasal cannula and is only sating at 86% SpO2. His respiratory rate is 25. MR jones  has been receiving chemotherapy for the past month for his lung cancer, however he hates how nauseous and weak it makes him feel, so he has decided to stop treatment. Mr. Jones also has chronic back pain, and his home pain regimen is proving to no longer be effective at managing his pain. Mr Jones is also very anxious and is intermittently tearful upon assessment.

1. A. Come up with 2 nursing diagnoses for Mr Jones – write out “r/t” and “AEB” statements for each, the best you can.

2. Determine which nursing diagnosis is your top priority for this patient.

2. For your top rated nursing diagnosis, come up with 1 patient outcome. Make sure this is written utilizing the SMART acronym.
3. For your identified patient outcome, write out 3 nursing interventions that you would implement to help the patient achieve their goal.

Answer 1

Chronic obstructive pulmonary disease is a significant risk factor for lung cancer. These patients are often suffering from shortness of breath, pain, lack of appetite and weight loss.

A. The nursing diagnosis are

1) Impaired breathing pattern related shortness of breath as evidenced by SPO2 86%.

2) Chronic pain on the back related to lung cancer as evidenced by pain scale reading and verbalization of patient.

The top priority is for impaired breathing pattern.

Patient outcome

The client maintains normal breathing pattern as evidenced by SPO2 more than 90% and normal respiratory rate.

Nursing interventions.

1) Assess the clients respiratory rate, SPO2, and abnormal braething sounds.

2) Provide semi fowlers position to the patient.

3) Clear the airway with proper suctioning and provide oxygen therapy

Good nursing care is neede to alleviate the symptoms and for better patient outcome.