What is the nursing care plan of the following scenario? Mr. Bryan L. was assessed and found to have the following signs and symptoms: awake, confused and agitated. He responds to your questions but sometimes he does not use appropriate terminology. He knows his name, but does not know he is in the hospital. He has productive cough, which he spits in the emesis basin. The sputum is thick and yellow, with streaks of blood. Mr. L. states, “I smoke 3 packs of cigarettes a day for many years and I’m going to keep on smoking!” Laboratory values reflect an elevated level of carbon dioxide in his blood. On minimal exertion, he is experiencing shortness of breath (dyspnea); respiratory rate is 29 breaths/min and uses his abdominal accessory muscles to breathe. Capillary refill is sluggish, greater than 3 seconds. Both of his hands and feet are pale and cold to touch. Assessment  Diagnosis Goal/expected outcome Planning Intervention Rationale  Evaluation     Objective data:   Subjective data:

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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What is the nursing care plan of the following scenario?

Mr. Bryan L. was assessed and found to have the following signs and symptoms: awake, confused and agitated. He responds to your questions but sometimes he does not use appropriate terminology. He knows his name, but does not know he is in the hospital. He has productive cough, which he spits in the emesis basin. The sputum is thick and yellow, with streaks of blood. Mr. L. states, “I smoke 3 packs of cigarettes a day for many years and I’m going to keep on smoking!” Laboratory values reflect an elevated level of carbon dioxide in his blood. On minimal exertion, he is experiencing shortness of breath (dyspnea); respiratory rate is 29 breaths/min and uses his abdominal accessory muscles to breathe. Capillary refill is sluggish, greater than 3 seconds. Both of his hands and feet are pale and cold to touch.

Assessment  Diagnosis Goal/expected outcome Planning Intervention Rationale  Evaluation

 

 

Objective data:

 

Subjective data:

           

 

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