Question

Please help

Patient with

Primary admission diagnosis: pneumonia

Patient with history of CAD, AS, Afib, on warfarin, COPD/emphysema. History of group B strep bacteria x3, CHF

Base on this patient please answer these question below

I. Nursing Diagnosis 1

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Evaluations

II. I. Nursing Diagnosis 2

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Evaluations

III. I. Nursing Diagnosis 3

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Evaluations

Answer 1

NURSING DIAGNOSIS :1

Ineffective airway clearance related to bronchospasm, increase production of secretion (thick ) as evidenced by abnormal breath sound, persistent cough, change depth and rate of respiration.

Goals :

• Maintain airway patency with breath sound clear.
• Demonstrate behaviour to improve airway clearance i.e.cough effectively.

Intervention :

• Assess and monitor respiration. Noting rate and sound.
• Auscultate breath sound.
• Note presence of dyspnea and respiratory distress .
• Assist patient with comfortable position elevated the head of bed.
• Administer bronchodialator iftar needed.

Evaluation :

• Patient breath sound clear.
• Persistent cough absent and airway clear.

NURSING DIAGNOSIS :2

Decrease cardiac output related to alteration in rate, rhythm, electrical conduction as evidenced by increased heart rate, change blood pressure, decreased urine output.

Goals :

• Patient will report decrease episode of dyspnea , angina.
• Patient will participate in activities that reduces cardiac workload.

Intervention :

• Auscultate pulse, assess heart rate and rhythm .
• Monitor blood pressure.
• Inspect skin colour i.e.pallor , cyanosis.
• Assess level of consciousness.
• Monitor urine output .

Evaluation :

• Heart rate and blood pressure is normal.
• Patient is conscious.

NURSING DIAGNOSIS :3

Acute pain related to decrease myocardial blood flow as evidenced by reports of pain.

Goal:

• Patient will report no chest pain.
• Patient will participate complete bed rest.

Intervention :

• Assess report of pain in jaw,shoulder and arm.
• Place patient complete bed rest.
• Elevated head of the bed.
• Monitor for heart rate and blood pressure .

Evaluation :

• Patient pain is reduced. According to pain scale (2/10).
• Patient feeling comfortable.