Question

Based on the below case study please answer the following:

Identify 3 nursing diagnoses.

Note the priority nursing diagnosis

Identify 1 goal for each diagnosis.

Note 4 interventions for the priority problems.

Case Study :

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.

Answer 1

a)Impaired gaseous exchange related to over-inflation of the alveoli as evidenced by decreased oxygen

Goal : to maintain normal oxygen level

Intervention:

Administer oxygen to meet oxygen demand

Provide nebulization to remove thick cough

Provide propped up position to increase lung capacity

Do ABG if directed

Monitor SpO2

b)Ineffective breathing pattern related to alveolar inflation as evidenced by wheeze,tachypnea, increase respiratory rate

Goal: improve breathing pattern

Intervention:

Provide propped up position

Administer bronchodialator as per the order

teach simple breathing exercises

Monitor vital signs

c)Altered thermoregulation related to fever as evidenced by increased temperature

Goal: to bring down her temperature to normal level

Intervention:

Monitor vital signs especially temperature

cold sponge helps to refuse temperature

Administer antipyeretic

emcorage to take plenty of oral liquids to keep illness at bay