Reference no: EM133398045

Case: Marty Moore is an 87-year-old obese man with a history of type 2 diabetes mellitus, hyperlipidemia, and hypertension, osteoporosis, hypertension, and COPD. He quit smoking last year after a 40-year history of one pack of cigarettes a day. For work he is a truck driver and reports eating a lot of fast food. He states, "it is hard to eat healthy on the road."

He had an exploratory laparotomy for a small-bowel obstruction 2 days ago.

VITAL SIGNS: Temperature 101° F, blood pressure 160/78 mm Hg, heart rate 100 beats/min, respiratory rate 24 breaths/min. SaO2 was 90%.

ASSESSMENT: He reports a cough kept him awake last night. On auscultation the nurse hears crackles in both lungs. The patient reports a sharp pain in his chest when he took the deep breath. After the deep breath for auscultation, the patient has a productive cough, and the nurse notices the sputum is green with rust-colored tinting. He states, "I try not to cough because it causes abdominal pain at my incision site." After morning care, he complains of feeling short of breath and dizziness during position changes. Upon inspection of the lower extremities, the nurse notes edema and has difficulty finding pedal pulses.

Question: Select two priority nursing diagnosis that apply to this scenario and provide a rationale for your choices? Write out the full nursing diagnosis that includes etiology. List below the assessments that contribute to the "as evidence by" to support the nursing diagnoses selected. Identify which assessments selected are objective and subjective. (Tip Use Ackley Care Plan textbook to assist with this question and utilize the defining characteristic sections