Question

Please Answer the Following Questions based on the below Criteria:

Patient

Age 75

Gender Female

Code status: full code

DPOA: None

Living will None

the patient arrived to ED with shortness of breath, cough

Admitting Dx: Hospital-acquired pneumonia

PMHX:

PVD

PE

DM

Afib with multifocal PVC

Pressure ulcer

Leukocytosis

toxic encephalopathy

appendectomy, AV fistula

Left cataract

Stent placement

Social history

Alcohol- no

Substance abuse no

living situation: lives in a rehab facility- Divorced

Mother died at 60 from breast cancer

worked in construction for over 20 years, lived independently until his medical condition

forced him to be placed in a rehab center.

Medications:

Humalog sliding scale

Renvela 1600mg po TID

Heparin 5000sq q 12 hours

Plavix 75mg daily

Norvasc 10mg daily

Labs:

WBC 13.7

Rbc 3.3

hgb 9.4

hct 29.7

Na 140

K+ 3.6

BUN 33

creatinine 5.2

Troponin 0.1

Question 1: Priority nursing diagnosis

Question 2: Outcome/Goal

Question 3: Interventions

Question 3a: Assessment/ Evaluation #1

Question 4: Potential Complications/ at risk for

Question 5: PC Outcomes/Goal

Question 6: PC Interventions

Question 7: PC Evaluation Plan

Answer 1

Nursing diagnosis are,

• Ineffective gas exchange related to disease condition
• Ineffective breathing pattern related to diseaase condition
• Exess fluid volume related to decreased urine output
• Hyper natremia and hyper volemiia related to disease condition
• Deficient knowledge related to disease condition

Goals are,

Maintain air way and oxygen saturation,releace hyper volemia and hyper natremia, control serum creat and urea,control blood glucose,and other potential complications

Interventions

assess the conditions of the patient

give fowlers positon to the patient

Administer oxygen to the patient

Apply foleys cath

limit the fluid diet

administer medications as prescribed

give hemodyalisis if needed.

Potential complications are,

Myocardial infraction

Renal dysfunction

Respiratory distress