Give a rationale for each nursing diagnosis listed below in regards to the scenario attached Jack Soo Park, a 78-year-old man receiving intravenous (IV) therapy with antibiotics, states, “I’m having trouble breathing. “ Vital signs include 156/88, Pulse 105, Respiratory Rate 30, Temperature 98.4F, and O2 Sat of 94% on 2LNC. It just started a little while ago. Physical examination reveals a bounding pulse; distended neck veins; shallow, rapid respirations; and crackles and wheezes in the lungs. Excess fluid volume is suspected. Further checking reveals an IV fluid-administration error that has resulted in overhydration. Nursing Diagnoses -Impaired gas exchange related to disease condition as evidenced by lung sounds. -Risk for excess fluid volume related to overhydration as evidenced by observation. -Risk for electrolyte imbalance related to excess fluid as evidenced by observation. -Risk for blood pressure instability related to reduced cardiac output as evidence for fluid volume changes.

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
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Give a rationale for each nursing diagnosis listed below in regards to the scenario attached Jack Soo Park, a 78-year-old man receiving intravenous (IV) therapy with antibiotics, states, “I’m having trouble breathing. “ Vital signs include 156/88, Pulse 105, Respiratory Rate 30, Temperature 98.4F, and O2 Sat of 94% on 2LNC. It just started a little while ago. Physical examination reveals a bounding pulse; distended neck veins; shallow, rapid respirations; and crackles and wheezes in the lungs. Excess fluid volume is suspected. Further checking reveals an IV fluid-administration error that has resulted in overhydration. Nursing Diagnoses -Impaired gas exchange related to disease condition as evidenced by lung sounds. -Risk for excess fluid volume related to overhydration as evidenced by observation. -Risk for electrolyte imbalance related to excess fluid as evidenced by observation. -Risk for blood pressure instability related to reduced cardiac output as evidence for fluid volume changes.
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