Utilizing The Patient Below Identify 3 Priority Problems Nursing Diagnosis And Create A Careplan Adpi For One Of Th 1 (83.38 KiB) Viewed 48 times
Utilizing The Patient Below Identify 3 Priority Problems Nursing Diagnosis And Create A Careplan Adpi For One Of Th 2 (78.63 KiB) Viewed 48 times
Utilizing the patient below, identify 3 priority problems (nursing diagnosis) and create a careplan (ADPI) for one of those problems ex: difficulty breathing. Background: Roberta Jones is a 75 year old female admitted yesterday evening after a 7 day history of chills, fever, productive cough with green sputum, shortness of breath, fatigue, decreased appetite and malaise. Her previous medical history (PMH) includes: COPD and osteoarthritis. Previous surgery was a cholecystectomy in 1989. Social history: Drinks 2 drinks per week. Smokes 2 packs of cigarettes per day. Divorced and lives alone. Has 3 children, all married. Daughter lives with her. She is restless and anxious and is trying to climb out of bed. Primary Medical Diagnosis: Pneumonia
Review of Systems CNS Awake, alert & oriented to name only. Confused, restless; Requires frequent reorienting to the environment. Patient is restrained due to confusion-she repeatedly took off her oxygen mask causing a drop in oxygen saturation. MAE slowly; pupils, equal, round, reactive to light. No deficits. Denies all pain or discomfort Cardiovascular S1 S2, no murmurs, bruits, or thrills, no JVD or peripheral edema; peripheral pulses (radial & pedal) +3, capillary refill WNL, skin, pale, cool, moist and intact. heartrate 117. Clubbing noted in R & L hands. Pulmonary Respirations rapid, labored with use of accessory muscles. C/O SOB. Lungs: coarse crackles bilaterally. Musculoskeletal WNL Integument Skin, pale, cool, moist and intact. Social Hx Married with 3 grown children, Retired accounting clerk. Drinks 2 alcoholic drinks per week. Smokes 2 pack of cigarettes per day. Current medications Albuterol Nebulizer Unit Inhal Q4h Atrovent Nebulizer Unit Inhal Q4h
Join a community of subject matter experts. Register for FREE to view solutions, replies, and use search function. Request answer by replying!