Joe Ritter, a 74-year-old retired bricklayer, has a 40-pack-year tobacco history and a history of chronic obstructive pulmonary disease (COPD). Today, he presents to the emergency department with reports of shortness of breath and difficulty breathing. He in respiratory distress with retracting respirations of 26 breaths/min, BP is 154/76 mm Hg, pulse is 120 beats/min, and temperature is 37°C.
His skin color is pale gray, his chest is barrel-shaped, and he uses accessory muscles to breathe; he appears anxious and is sitting in a tripod position. His nail beds are bluish in color; his oxygen saturation by pulse oximetry is 72%.
Chest auscultation reveals wheezes and decreased-to-absent breath sounds in bilateral bases. Hyperresonance is noted upon chest wall percussion. Chest x-ray showed atelectasis bilaterally in the bases. Mr. Ritter coughs with minimal amounts of clear sputum. (Learning Objectives 5 and 8)
|
Nursing Diagnosis 1: |
|
|
Goals: (Expected Outcome, long and short term)
Outcome: |
|
|
Nursing Interventions: (How am I going to fix this problem?) 1. 2. 3.
|
Rationales: (Why did I choose these interventions? Why will they work?) 1. 2. 3.
|
|
Evaluation: (How do I know my interventions were effective?)
Goal # 1.
Goal # 2. *REPEAT THIS CHART FOR EACH NURSING DIAGNOSIS, TOTAL OF 3* |
Trending now
This is a popular solution!
Step by step
Solved in 4 steps
