Question

Harry Smith, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago. The patient smoked cigarettes one pack per day for 55 years and quit 3 years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 101 bpm, respiratory rate 28 breaths/min, and temperature 101.5°F. The pulse oximeter on room air is 85%. The CBC is as follows: WBC 12,500, platelets 350,000, HCT 30%, and Hgb 10 g/dL. ABGs on room air are pH 7.30, PaO2 55, PaCO2 50, HCO3 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum. What is NANDA nursing care plane for this patient?(3 priorities nursing diagnosis)

Answer 1

1.Ineffective airway clearance related to hypersecretion as evidenced by sputum,dypnea,decrease oxygen level,cyanosis

Goal: to relieve the patient from breathing difficulty

Subjective data:Nil

Objective data:tachypnea, shortness of breath,spo2 decreased,changes in chest x ray,diaphoretic,using accessory muscles for breathing,cough

Intervention and rationale :

• Administer oxygen to relieve hypoxia
• Provide propped up position to increase the lung capacity
• Monitor vital signs to know the status and base line
• Administrator medication as per order to relieve shortness of breathand symptomatic treatment
• Assess for capillaries perfusion

2)Ineffective tissue perfusion related to decreased blood pressure adds evidenced by vitals,diaphoresis,decrease capillary perfusion

Goal : to bring the blood pressure to normal

Subjective data:Nil

Objective data : decreased blood pressure, increased heart rate

Intervention and rationale :

• Monitor vital signs (BP and heart rate ) to prevent any deformation by preventing complications
• Administer IV fluids to increase the fluid volume and thereby increasing the blood pressure
• Elevate lime for effective circulation to the heart and decreasing its work load
• Assess for capillary repercussion
• Administer medication as per order

3)Altered sensorium related to changes in body's vital function as evidenced by confusion, increased PaCo2

Goal:will gain normal reality to orientation and consciousness

Subjective data: confused

Objective data:confusion

Intervention and rationale

• Assess GCS to get baseline data
• Treat physiological changes to regain consciousness
• Provide safety measure to prevent falls
• Encourage family members to involve in reorienting the patient
• Try to convey all the procedure to gain confidence and participation
• Administer medication as per order