Question

Joe Davis, a 62-year-old patient, is admitted to the hospital with chest injuries after a motor vehicle crash. The client has a history of type 1 diabetes. While assessing the patient, the nurse notes that the patient has several clusters of dull red bumps, smaller than a pencil eraser, spreading to an area the size of a quarter on each lower anterior leg. The skin in the lower extremities is thick; leathery; and has waxy, yellow coloration.

Scenario specifics: Consider Diabetic dermopathy and Stasis dermatitis

You have been given this patient to take care this morning at 7:00 AM, and your shift ends at 7:00 PM

Develop a non pharmacological care plan for this patient with an appropriate priority ND and interventions for this patient. By sure to include a teaching intervention. All your non teaching interventions must be on the priority ND. Please answer the following questions according to the scenario.

1. What is the priority nursing diagnosis for this patient in NANDA format?

2. What is the risk diagnosis for this patient?

3. What is a short term goal based on the priority nursing diagnosis?

4. What is a long term goal based on the priority nursing diagnosis?

5. What are 2 non-pharmacological interventions based on the priority nursing diagnosis?

Answer 1

1, The nursing diagnosis are,

Ineffective breathing pattern related to decreased lung expansion

• Decreased cardiac output related to mediastinal shift
• Accute chest pain related to the trauma,pressure in the chest cavity and chest tube
• Risk for infection related to traumatic injury and chest tube insertion
• Fear related to breathing difficulty

2,RIsk diagnosis

• Risk for infection related to traumatic injury and chest tube insertion
• Risk for hypoxia related to improper chest expantion
• Risk for sking infection related to diabetic condition

3,short term goals are,

• Prevent hypoxia,
• Analgesia
• prevent mediastinal shift
• encourage deep breathing and coughing exercises
• keep the patient calm
• prevent further infection and treat diabetis and diabetis dermopathy

4,Long term goals are,

• Prevent further infection
• Manage diabetis and prevent complications like diabetic neuropathy,retinopathy,and nephropathy and gangrines
• Retain body figure
• Excercise and physio therapy for prevent future breathing problems

5,non pharmacological managements are,

• invasive or non invasive ventilation for the support of respiration if intercostal muscles are affected
• physio therapy to fesilitate normal breathing and drain the secreations
• dietary management for control diabetis
• counciling for eliminate fear and anxiety

plz give a thums up