Question

60 years old ,male , DM Type 2 , HTN since 20 years ,smoker ,family history of IHD ,
Pt said i have shortness of breath increasing by supine position and decreased with sitting position ,like heaviness,intermittent ,started yesterday at 6pm,associated with dry cough ,sleep at night using 4 pillow to sleep
Pt said ihave swelling in my rt and lft foot,ankle worsen when stand or dangling the leg ,decrease with elevate the leg since one month and increase in wt over time
General appearance pale ,pt wt. 90 kg ,ht 180cm cooperative good hygiene ,sitting position,oriented to time place person
VS
Heart rate 110 b/m 2 in right radial pulse irregular
Bp 95/60 mmhg in sitting position
R.R 24 cycle /minute shallow ,with effort using accessory muscle
Temperature 36.5 c orally
Medication
O2 support
Lasix 60mg iv 1*1
Spironolactone 25 mg tab 1*1
Aspirin 100mg 1*1
Physical exam :
Pitting oedema 2 over both foot
Auscultation crepitation lateral right and left lung
Skin cool pale
Abnormal lab result
O2 sat 89%
Hb 9mg /dl
Na 131
ECG SINUS TACHYCARDIA
CX RAY congested both lungs

Read and answer the following questions about the case:

1. Mention two subjective data and two objective data.

2. Mention two nursing diagnoses with problem statement, etiology and manifestations

3. For the above nursing diagnosis continue the nursing care plan including planning, interventions with rationales and the expected evaluations

4. What’s classification of Lasix?

5. interpret 02 sat 89%

Answer 1

1. Mention two subjective data and two objective data.

SUBJECTIVE DATA

1. Pt said” I have shortness of breath increasing by supine position and decreased with sitting position ,like heaviness,intermittent ,started yesterday at 6pm,associated with dry cough ,sleep at night using 4 pillow to sleep”

2. Pt said “I have swelling in my rt and lft foot,ankle worsen when stand or dangling the leg, decrease with elevate the leg since one month and increase in wt over time”

OBJECTIVE DATA.

1.Pitting oedema 2 over both foot,Auscultation crepitation lateral right and left lung, Skin cool pale

2 . Vital Signs shows

• · Heart rate 110 b/m 2 in right radial pulse irregular
• · Bp 95/60 mmhg in sitting position
• · R.R 24 cycle /minute shallow ,with effort using accessory muscle
• · Temperature 36.5 c orally

2. Mention two nursing diagnoses with problem statement, etiology and manifestations

1. Ineffective breathing pattern related to congested lungs as manifested by shortness of breath increasing by supine position and decreased with sitting position ,like heaviness, intermittent dry cough ,sleep at night using 4 pillow , Auscultation : crepitation lateral right and left lung

2. Flu id volume excess relate to Compromised regulatory mechanisms as manifested by shortness of breath : orthopnea/dyspnea, Abnormal breath sounds: crepitation lateral right and left lung Decreased Hb (9mg /dl), Tachycardia( 110 b/m 2 in right radial pulse irregular), swelling in rt and lft foot,ankle worsen when stand or dangling the leg ,Pitting oedema 2 over both foot

3. For the above nursing diagnosis continue the nursing care plan including planning, interventions with rationales and the expected evaluations

Nursing diagnosis	Planning goals	Intervention	Rationale	Evaluation
1. Ineffective breathing pattern related to congested lungs as manifested by shortness of breath increasing by supine position and decreased with sitting position ,like heaviness, intermittent dry cough ,sleep at night using 4 pillow , Auscultation : crepitation lateral right and left lung	At the end of nursinginterventions,patient will beable to: 1. Report feeling comfortable when breathing	Establish rapport with patient 2. Instruct patient to increase oral fluid intake to 8-10 glasses 3. Instruct patient to do deep breathing exercise after demonstrating proper technique 4. Keep environment allergen free (dust, feather pillows, smoke, pollen) 5. Take and VS 6. Suction naso, tracheal/oral PRN 7. Educate proper hand washing 8. Position the patient in semi fowler’s position 9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat 10. Review client’s chest x-ray for severity of acute/ chronic cond Establish rapport with patient 2. Instruct patient to increase oral fluid intake to 8-10 glasses 3. Instruct patient to do deep breathing exercise after demonstrating proper technique 4. Keep environment allergen free (dust, feather pillows, smoke, pollen) 5. Take and VS 6. Suction naso, tracheal/oral PRN 7. Educate proper hand washing 8. Position the patient in semi fowler’s position 9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat 10. Review client’s chest x-ray for severity of acute/ chronic cond Establish rapport with patient 2. Instruct patient to increase oral fluid intake to 8-10 glasses 3. Instruct patient to do deep breathing exercise after demonstrating proper technique 4. Keep environment allergen free (dust, feather pillows, smoke, pollen) 5. Take and VS 6. Suction naso, tracheal/oral PRN 7. Educate proper hand washing 8. Position the patient in semi fowler’s position 9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat 10. Review client’s chest x-ray for severity of acute/ chronic cond Establish rapport with patient 2. Instruct patient to increase oral fluid intake to 8-10 glasses 3. Instruct patient to do deep breathing exercise after demonstrating proper technique 4. Keep environment allergen free (dust, feather pillows, smoke, pollen) 5. Take and VS 6. Suction naso, tracheal/oral PRN 7. Educate proper hand washing 8. Position the patient in semi fowler’s position 9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat 10. Review client’s chest x-ray for severity of acute/ chronic cond Establish rapport with patient 2. Instruct patient to increase oral fluid intake to 8-10 glasses 3. Instruct patient to do deep breathing exercise after demonstrating proper technique 4. Keep environment allergen free (dust, feather pillows, smoke, pollen) 5. Take and VS 6. Suction naso, tracheal/oral PRN 7. Educate proper hand washing 8. Position the patient in semi fowler’s position 9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat 10. Review client’s chest x-ray for severity of acute/ chronic cond Establish rapport with patient 2. Instruct patient to increase oral fluid intake to 8-10 glasses 3. Instruct patient to do deep breathing exercise after demonstrating proper technique 4. Keep environment allergen free (dust, feather pillows, smoke, pollen) 5. Take and VS 6. Suction naso, tracheal/oral PRN 7. Educate proper hand washing 8. Position the patient in semi fowler’s position 9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat 10. Review client’s chest x-ray for severity of acute/ chronic cond · Assess and record respiratory rate and depth at least every 4 hours. · Observe for breathing patterns · Assess the position that the patient assumes for breathing. Encourage sustained deep breaths by: · Using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation · Utilizing incentive spirometer · Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing. · Educate patient about medications: indications, dosage, frequency, and possible side effects. Incorporate review of metered-dose inhaler and nebulizer treatments, as needed.	· It is important to take action when there is an alteration in the pattern of breathing · Unusual breathing patterns may imply an underlying disease process or dysfunction. · These techniques promotes deep inspiration, which increases oxygenation and prevents atelectasis. · This facilitates adequate clearance of secretions. · This information promotes safe and effective medication administration.	Patient maintained normal breathing pattern

Nursing diagnosis	Planning goals	Intervention	Rationale	Evaluation
. Flu id volume excess relate to Compromised regulatory mechanisms as manifested by shortness of breath : orthopnea/dyspnea, Abnormal breath sounds: crepitation lateral right and left lung Decreased Hb (9mg /dl), Tachycardia( 110 b/m 2 in right radial pulse irregular), swelling in rt and lft foot,ankle worsen when stand or dangling the leg ,Pitting oedema 2 over both foot	· Patient will verbalizes awareness of causative factors and behaviors essential to correct fluid excess.	· Monitor weight regularly using the same scale and preferably at the same time of day wearing the same amount of clothing · Monitor input and output closely. · Elevate edematous extremities, and handle with care. · Educate patient and family members regarding fluid volume excess and its causes. · Explain the need to use antiembolic stockings or bandages, as ordered.	· . Sudden weight gain may mean fluid retention. · Dehydration may be the result of fluid shifting even if overall fluid intake is adequate. · Elevation increases venous return to the heart and, in turn, decreases edema. Edematous skin is more susceptible to injury. · Information is key to managing problems · These aids help promote venous return and minimize fluid accumulation in the extremities.	Patient maintained normal fluid volume

4. What’s classification of Lasix?

Drug class: Loop diuretic, Diuretic

Trade Name

· Lasix (furosemide)

· Classification
diuretics

Pharmacologic Class.
loop diuretics