Oxygenation - Patient 2 K Patient Data History and Physical Nurses' Notes Imaging Studies Select a tab to see patient information The nurse analyzes assessment data and health history from the medical record to determine if any additional information should be collected. Select the 4 assessment activities the nurse can utilize to gather additional information to establish the significance of the collected client cues related to oxygenation and impaired gas exchange. Assess intake and output Ask about the client's mental status Administer seasonal vaccines Elevate the head of bed to 45 degrees Inspect skin and mucous membranes Inquire about the client's activity level Teach deep breathing and coughing exercises Observe respirations for rate, rhythm, and depth
The client is a 77-year-old man admitted to the hospital with chronic obstructive pulmonary disease (COPD). He smoked two packs of cigarettes per day for more than 50 years and states he quit smoking 10 years ago. He also has a history of hyperlipidemia.
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The 77-year-old male client has a productive cough with thick, green secretions. Heart sounds are muffled. Breath sounds are diminished bilaterally with inspiratory and expiratory wheezes noted. The client denies pain, rating his pain a 0 on a 0-to-10 pain scale. He reports dyspnea (difficulty breathing). His chest is barrel shaped. The client ate only 25% of his breakfast today.
Vital signs: temperature 98.4° F (36.9° C), pulse 96 beats/minute and regular, respirations 24 breaths/minute and labored, BP 140/74 mmHg, oxygen saturation 90% at rest on 2 L of oxygen via nasal cannula.
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Chest x-ray: Increased density in the right lower lobe.
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