Nursing Interventions

The client is a 66 year-old female who weighs 154 lbs and is 5 ft, 4 in tall. She lives with her retired husband. They own their own home and live with their three dogs. The client watches her 3 year-old granddaughter 2 days per week. She saw her MD today, who admitted her to the hospital for her recent weight gain of 15 lbs, shortness of breath with activity, and ankle edema. Per the patient her symptoms have been going on for 1 week. She denies recent serious illness, trauma or surgery.Assessment reveals a well-nourished female who is dyspneic, has crackles in the lower lung fields bilaterally, and has 2+ pitting edema of lower extremities (ankles) bilaterally. Her oral temperature is 99.4 F/37.4 C, and her blood pressure is 166/94. Her atrial heart rate is 99 beats per minute, and regular. Her respiratory rate is 30 breaths per minute and her oxygen saturation is 91% on room air. 1.) Assessment-Specify what is abnormal in the assessment, and which data is a priority for your to address. **What medical diagnosis do you think this patient might have going on? 2.)Nursing Diagnosis-Create 3 appropriate nursing diagnoses by matching the parts below into complete nursing diagnoses (R/T = related to & AEB = as evidenced by): Ineffective Breathing Pattern Decreased Cardiac Output  Risk for Fall  R/T altered contractility  R/T increased respiratory rate  R/T dyspnea with activity and pitting peripheral edema AEB crackles, dyspnea and peripheral edema AEB crackles bilaterally and O2 sat 91%(Problem) (Etiology) (Symptoms)1.)2.)3. )3.) Planning-Identify 3 priority nursing interventions for this client (based on the above nursing diagnoses) 4.) Implementation-Explain how you will implement your 3 priority nursing interventions and whether they are “direct” or “indirect” interventions 5.) Evaluation-Evaluate the previous 4 steps of the nursing process, and talk about what your expected outcomes are for this client at time of discharge Formulate a Concept Map for Client (Medical Diagnosis) (Nursing Dx #1) (Assessment Data)(Nursing Interventions)(Nursing Dx #2)(Assessment Data)(Nursing Interventions)(Nursing Dx #3)(Assessment Data)(Nursing Interventions)


In: Nursing



In: Nursing

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