Question

Apply the nursing Process to the following

Hypothetical situation

Mrs. Rojas, 30 years old, came to the emergency room with a cold two weeks ago, she presented dyspnea (difficulty breathing). It indicates that you have a fever, headache for several days, chest pain, and you have to sit up to breathe well. Also, complaints of chills have decreased fluid intake 2 days ago. On physical examination temp. 39.5C, pulse 92 reg., Strong, Resp. 22 / min. Superficial. B / P 122/80., Dry mouth mucosa, pale, hot skin, reddened cheeks. Decreased vesicular and crackling sounds on inspiration in the right upper and lower lobe. Its thoracic expansion is 3 cm., Scant cough, dense sputum of light pink color. Lethargic, weak, and fatigued appearance. The doctor suspects that this may have the diagnosis Influenza A H1N1.
After reading the situation, answer the following questions;
1.After reading and analyzing the situation, identify the estimated data, and classify them as subjective and objective.

2. Mention the problems that you infer in this situation?

3. According to the NANDA category, which nursing diagnosis applies in this situation. (It must include Problem, etiology and symptoms).

4. Develop the expected result for this Situation

5.Develop nursing interventions such as coordinating and managing
Care of this patient, include the nursing orders and justification for each intervention. (Complete the table).

                   Nursing orders                                    Justification                              

6. Mention what legal ethical implications should be considered in this condition.

7. List and define the six nursing steps and define them.

outcome

Care providers to individuals in different settings, understanding cultural variations, effective communication based on their learning style.
 Coordinator and care manager in situations that require problem-solving and uses principles of delegation when warranted.
Practice the profession according to the legal framework of the profession's standards.
Uses the nursing process as a framework to develop, implement, and evaluate the care plan for the healthy individual or with a minimum of alterations.
 Information management.

Answer 1

Q.N.1

Subjective data: Subjective data means, its the patients own description about how she is feeling, what are her complaints, what are the problems she facing because of her illness etc. Every time record the sunjective data in patients own words. LIke " I have severe pain since last 2 days"

Objective data: The information collected from the family members, other care givers, by performing the physical examination, examining the laboratory data etc. Most of the signs elicited by the physician, nurse, observation findings etc comes under objective data.

Subjective data here( patients own complaints)

• Complaints of cold two weeks ago
• Dyspnea (difficulty breathing) need to sit up to breath well
• Fever, headache for several days
• Chest pain
• Complaints of chills
• Decreased fluid intake

Objective data here( Findings by assessment)

• Body temp. 39.5C
• Pulse 92 reg., Strong,
• Resp. 22 / min.
• B / P 122/80.
• Dry mouth mucosa, pale, hot skin, reddened cheeks.
• Decreased vesicular and crackling sounds on inspiration in the right upper and lower lobe
• Thoracic expansion is 3 cm
• Scant cough, dense sputum of light pink color.
• Lethargic, weak, and fatigued appearance.

Q.N.2 : Mention the problems that you infer in this situation?

Based upon the clinical examination and assessment findings, her symptoms are suggestive of lobar Pneumonia.Patient had complaints of breathing difficulty, chest pain, Decreased vesicular and crackling sounds on inspiration in the right upper and lower lobe, scanty cough in light pink color etc. Which may suggest a lobar pneumonia.

Q.N.3. According to the NANDA category, which nursing diagnosis applies in this situation. (It must include Problem, etiology and symptoms).

• Impaired breathing pattern related to thick retained secretions as evidenced by difficulty in breathing except in upright position.
• Impaired gas exchange related to thick secretions as evidenced by dyspnoea.
• Ineffective airway clearence related to decreased energy and fatigue as evidenced by ineffective cough.

Q.N.4. Develop the expected result for this Situation

The patient must experience reduction from her breathing difficulty and maintain a normal respiratory pattern with signs of good respiratory exchange. She should experience reduction from her fatigue, and maintain her vital signs within the normal limit. Her respiratory system shoul work effectively and she must develop normal breath sounds on auscultation.

Q.N.5. Nursing orders and justifications