Question

I. One (1) complete actual nursing diagnoses,

II. One (1) complete risk/potential

III. Five nursing intervention per diagnosis (two interventions should involve teaching)

IV. One short term goal

V. Objective and Subjective data

VI. Evaluation for the care

You are a nurse admitting a patient to the hospital from the emergency

department (ED) with shortness of breath and recent weight loss. After receiving

a report from the ED nurse, you ready the patient’s room according to unit

specifications and collect the necessary equipment and forms. When the patient

arrives, she is using oxygen via a nasal cannula and seems to be comfortable.

As you begin your admission activities and paperwork, you note that her

shortness of breath slightly increases as she answers your questions.

Accompanying the patient is her daughter, who comments, “This is the fourth

time she’s been admitted to this hospital in the past year.” The patient and her

daughter demonstrate a close, loving relationship. The daughter not only

encourages her mother but also sets boundaries regarding her mother’s anxiety.

Answer 1

I. Ineffective breathing patteren related to disease condition ,and anxiety as evidenced by increased respiratory rate, dyspnea, irritability.

II.Risk for temporary or permanent cognitive impairment related to less oxygen supply to the brain.

III.

A. Intervention for diagnosis no. 1

a. Establish rapporr with the patien.

b. Assess patient condition, measure vital signs and record it.

c. Provide oxygen with cannula as prescribed.

d. Teach patient deep breathing and coughing exercise.

e. Teach patient mental relaxation techniques .

B. Intervention for diagnosis no. 2

a. Monitor vital sign in every 30 min interval and record it.

b. Elevate the head of the bed and change the position of patient every 2 hours interval.

c. Encourage patient to take more fluid.

d. Teach patient diaphragmatic breathing.

e. Teach patient how to balance between rest and physical activity.

IV. At the end of the nursing care patient will restore normal breathing pattern as manifested by absence of shortness of breath and normal respiratory rate.

V. Subjective data : none

Objective data: dyspnea , restlessness ,anxiety.

VI. 1.Patient will manifest signs of decreased respiratory effort.

2. Patient verbalized feeling comfortable while breathing.

3. Patient verbalized that her anxiety is ness.