Reference no: EM132923388

Client with Pneumonia

Mr Edwards is a 75 yr old man who has a history of chronic obstructive pulmonary disease for the last two years. He continues to smoke ½ pack of cigarettes a day and does not participate in any exercise regimen and must do self-care activities slowly because of fatigue. He does not see any reason to increase his fluid intake. Presently, he is admitted for right upper lobe pneumonia and reports having an intermittent cough that produces thick, yellow sputum. He has more episodes of coughing when lying flat. He is married and his wife, Kathy is at his bedside.

Assessment

Mr Edwards SpO2 ranges from 78%-84%, and currently this am is 84%. His other vital signs are T 101.4F, HR 102/min, RR 30/min, BP 130/90mmHg. He is chilled and has had some diaphoresis. He reports that his ribs are sore and that his mouth is dry. Upon inspection, Mr Edwards mucous membranes are dry, as is his skin. Crackles are auscultated in the lower lobes bilaterally. His sputum is thick, and a yellow to yellow green in color. His health care provider has told him that if he gradually increases his exercise, drinks more fluids and stops smoking, his respiratory status will improve. He is lying in a semi-fowlers position in bed.

Question 1: What relevant assessment data would you cluster to support a nursing diagnosis?

Question 2: What priority nursing diagnosis would you identify for this patient? List five and give both Problem focused and Risk for nursing diagnoses.

Question 3: What short term goal would you identify for the priority nursing diagnosis you identified? What long term goal would you identify?

Question 4: List all the nursing interventions that you would perform for identified goals and nursing diagnosis. Give a rationale for each.

Question 5: If you implemented all of the identified interventions, how would you evaluate that your interventions were successful and that the goals were met?