Question

Scenario: M.W. is a 65-year-old female. She is a retired auto worker who lives in a condo with her golden retriever, Charlie. She has a history of diabetes type II diagnosed 3 years ago. She had a myocardial infarction in 2012. She does not exercise. She denies smoking or alcohol use. She was feeling fine until yesterday. A&O x4, shortness of breath on exertion, fine crackles in bilateral lower lobes, O₂saturation 89% on RA. S₁and S₂audible without murmur, cap refill >2 secs lower extremities, <2 secs in upper extremities. Vitals: BP 100/60, HR 84, RR 28, Temp 36.1C. Ht: 5’ 5” Wt: 200 lbs.

Question: What nursing diagnosis takes priority? Why?

(P.S. please have answer be in depth).

Answer 1

Nursing Diagnosis :

Ineffective breathing pattern due to decreased blood supply to lungs as evidenced by dyspnea, hypoxia,increased respiratory rate,fine crackles

(A patient can exhibit breathlessness when there is a problem associated with heart or lungs)

Goal :

To make patient breath normally

Subjective data :

• Shortness of breath

Objective data :

• Dyspnoeic
• Fine crackles on auscultation
• Decreased SPO2
• Increased respiratory rate

Nursing intervention and rationale :

• Provide propped up position to promote lung expansion
• Assess the patient for peripheral vascular disease as the capillary refill is greater than 2 seconds in lower limbs
• Administer oxygen to relieve hypoxia
• Administer IV fluids to improve blood pressure as decreased blood supply will lead to shortness of breath
• Administer medication as per order to relieve shortness of breath
• Restrict any activity which may aggrevate breathing difficulties

Evaluation

The patient should be able to breath easily and comfortably