Question

Case study #2

Mrs.G, age 70, calls the nurse to report her concern of a constant irritating cough. The physical assessment findings indicate that the patient is short of breath, her respirations are 32 and labored, and she has crackles bilaterally on auscultation. She has swollen ankles and 2+ pitting edema to her feet bilaterally. Her blood pressure is 190/110, pulse 120 and bounding. She has a history of congestive heart failure and hypertension.

Question 1: Identify a priority problem the nurse would be concerned about and the objective data that supports your conclusion. What is the priority nursing diagnosis based on these symptoms?

Question 2: List appropriate nursing interventions and how the nurse would evaluate the effectiveness of each intervention related to the priority nursing diagnosis that you have identified.

Answer 1

QUESTION 1:

ANSWER: The priority should first focus on airway or breathing problems. Shortness of breath should be the first priority problem to be managed. It is because if we delay management of problem-related to airway or breathing will to hypoxia and death of the person soon.

Objective data means what the nurse observe or find out from the patient. In this patient, he is having labored breathing, irritating cough, crackle bilateral sound on auscultation.

The priority nursing diagnosis are

1. Ineffective breathing pattern related to pulmonary edema as evidence by shorth of breath. (pulmonary edema is a complication of heart failure)

2. Decrease cardiac output related to decreasing ventricular filling as evidence by increased blood pressure and tachycardia.

3. excess fluid volume related to sodium and water retention as evidence by the presence of edema in the ankle.

Question 2:

1. Ineffective breathing pattern related to pulmonary edema as evidence by shortness of breathing

Intervention

- Assess the breathing pattern of the patient and Spo2 level.

- assess the breath sound

-administered oxygen to the patient

- provide fowler position or head-up position to manage shortness of breath

-encourage to perform breathing and coughing exercise

- provide proper rest

- encourage to take low salt and restrict fluid intake.

Evaluation

- The patient will minimize labor respiratory breathing

2. Decrease cardiac output related to decreasing cardiac filling as evidence by increased blood pressure and tachycardia.

Intervention

-monitor blood pressure and pulse frequently

- assess for any color change or coldness of extremities

- Administer drugs like digoxin or antihypertensive drugs as per prescribed by the doctor

- Advised to take low salt and restrict fluid intake

- provide a comfortable position

Evaluation

- it can be evaluated by the chacking of cardiac output or decreased in blood pressure and normal pulse rate.

3. Excess fluid volume related to sodium and water retention as evidence by presence of swelling or edema in the ankle

intervention

- check the weight every day

- check the intake and output urine amount of the patient

- restrict fluid intake

- Restrict the sodium-rich diet

- Elevation of the feet should be done

- Inspect the skin for any kind of rupture or injury and give proper skincare

- Administered diuretic after advice by the doctor.

Evaluation

the intervention will be effective if the edema is reduced.

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