Identify 3 nursing diagnoses. Note the priority nursing diagnosis Identify 1 goa

Question

Identify 3 nursing diagnoses.

Note the priority nursing diagnosis

Identify 1 goal for each diagnosis.

Note 4 interventions for the priority problems.

Gladys Hammer is an 83 year old female who is seen in the emergency department with complaints of shortness of breath and fever. Her vital signs are T. 102 F, P115, and irregular, shallow respirations at 35, B/P 168/66. Her height is 5ft 3 in and weight is 96 pounds. On assessment, her skin is very dry and warm. Her color is dusky. Scattered wheezes and rhonchi are heard throughout all lung fields. Her chest is hyperresonant to percussion. A pulse oximeter is applied and the O 2saturation is reading is 88%. Mrs. Hammer has a past history of emphysema for 10 years, complaints of shortness of breath on exertion, and has a chronic cough productive of thick, grayish sputum. Her spouse passed away 5 years ago and she has lived with her two adult sons since then.

Explanation / Answer

3 or more Nursing Diagnosis:

-Shortness of breath, wheezing, rhonchi

-Fever

-PMH of emphysema

-chronic cough

Priority Nursing Diagnosis:

-Shortness of breath

-Fever

-Chronic cough

Interventions:

-Position the patient at 45 degree angle for easy breathing with slightly raising the foot bed to avoid patient slipping.

-Encourage sustained deep breaths as it endorses deep inspiration, which upsurges oxygenation and avoids atelectasis.

-Eliminate excess blankets when the patient senses warmth and offer extra warmth when the patient feels chilled.

-Offer TSB with the temperature of water being 80-99°F. This is to improve heat loss by evaporation and conduction.

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