Question

NR226 Nursing Process Practice Patient ted with localized infection d/t spider bite falls, left hip fx lanuary 2017 w/ORIF, Stage II pressure ulcer on coccyx 78 y/o M admitted pneumonia, UT owel sounds hypoactive x4, si 52 present without murmurs, HR Regular, no edema, +3 bilateral radial and pedal. Stage II wound measures 3x2cm with small amount of BP136/78, HR 91, RR 20, Temp 39.0. Pt states that he has an ill wife at pulses home and none of his children live around the area. Pt verbalizes feeling lonely and does not oant to eat much d/t SOB and feeling depressed. Pt constantly uses call ight. Pt has persistent cough, frequent SOB at rest. Orders: 02@ 21 NC, cBC, CMP, ABGs q24 hrs, med nebs PRN, 1800 ADA diet, send culture of coccyx wound, wet-to-dry dressing change on coccyx bid& PRN drainage Underline SUBJECTIVE DATA in blue ink Underline OBJECTIVE DATA in red ink Be ready to create a plan of care for Dobby using the nursing process. We will be drawing a concept map on the board together during the next lecture
Can someone please help me with the actual nursing diagnosis.......... like name them with correlation to the actual story

Answer 1

Subjective data: Feeling depressed, shortness of breath , Cough at rest and thick yellow sputum at times.

Objective data:Patient is alert, conscious , oriented to person , place and time. Pupils equal and reactive to light and accomodation.Crackles heard bilaterally and diminished backward upward lateraly. Hypoactive bowel sounds in all four quadrants with reduction in the loudness, tone, irregularity of the sounds.Heart rate regular with S1S2 ,no cardiac murmurs. Pedal and radial pulses normally palpable, regular, and of the same strength between the right and left. Ulcer in coccyx with purulent drainage .BP- 136/78, HR-91, RR-20, TEMP- 39.0.

Actual nursing diagnosis:

1. Ineffective airway clearance related bilateral crackles,cough related to retained secretions as evidenced by thick yellow sputum at times

• Provide oxygen through mask
• Monitor respiratory pattern : Rate, depth and effort
• Monitor oxygen saturation, blood gas values
• Provide good position to optimize respiration
• Provide nebulisation

2.Impaired skin Integrity related to pressure ulcer as evidenced by presence of stage B wound in coccyx

• Assess skin color , temperature
• Turn patient every two hourly
• Provide additional pillows
• Provide necessary dressing

3. Functional urinary incontinence related to psychological factors(depression) as evidenced by wound in coccyx

4.Hopelessness related to decreased appetite as evidenced by hypoactive bowel sounds