Read the scenario carefully. I'm going to make the nursing care about the respiratory. Please help me. Linda Cerullo is
Posted: Mon Apr 04, 2022 6:52 am
Read the scenario carefully. I'm going to make the
nursing care about the respiratory. Please help me.
Linda Cerullo is a 56-year-old female who was brought to the
hospital by ambulance on January 25, 2021. She presented to
the emergency department and was diagnosed with left sided
bacterial pneumonia. She has a history of iron deficiency,
high cholesterol and hypertension. Past surgical history
includes a caesarian section. She is taking ramipril 10mg PO,
daily, atorvastatin 20 mg PO, daily and ferrous fumarate, 300 mg,
PO BID. She has an IV of 2/3 & 1/3 running at TKVO in her
left hand and is currently on IV ceftriaxone 1gm q24 hours plus
Tylenol 1g, PO q6H prn for fever or pain. Linda is currently
a secretary at a dental office. She lives at home with her husband
and her adult daughter. She is Italian by birth and attends
Roman Catholic mass weekly. At home the family speaks Italian but
she is fluent in English. She is a full code status and has
allergies to penicillin and vancomycin. Linda wears reading
glasses.
Today is the second day of her admission and you are the nurse
caring for her on the medical unit. Upon your assessment her vital
signs are temp 38.9 degrees Celsius, pulse (radial) 99 beats/min,
RR 24/min, BP 118/79 and O2 sat 92% on 2L of oxygen via nasal
prongs. You use your stethoscope to auscultate her chest and
note decreased breath sounds to the LLL. She has a productive
cough still and complains of being short of breath frequently.
You ask her to sit up in the bed and notice that she becomes
increasingly short of breath with bed mobilization. There is
evidence of accessory muscle use (abdominal breathing).
When asked if she has any pain the patient states "Yes I have
pain when I breathe deeply or cough." She rates her pain as 2/10 at
rest and 6/10 when breathing deeply or coughing. You ask
Linda when she first noticed the pain, "I first noticed the pain at
5am today". Linda explains to you that she is feeling "unwell
and tired". She expresses frustration with her inability to
sleep due to noise in the hallway at night. She also reports
difficulty in getting into a comfortable position to rest as she
normally sleeps on her side at home but gets very short of breath
when lying down now. You notice she is short of breath during the
interview. She can get no more than two words out before
having to stop talking and rest.
You compare that to the blood pressure that the previous nurse
had obtained overnight from the patient. Her blood pressure
overnight was 99/69. You recognize that this was lower than
normal and ask her if she gets dizzy or lightheaded. She tells you
that she is not now but sometimes when she gets up suddenly she
does get dizzy and lightheaded.
Linda also expresses frustration to you about being constipated,
"I think I need some bran flakes. I haven't had a bowel
movement in 2 days". She says that her medication makes her
constipated but at home she is active and drinks more fluid to
assist with this. Her abdomen does appear distended. You auscultate
for bowel sounds and note that they are hypoactive in all 4
quadrants. You palpate all four of her abdominal quadrants and note
they are slightly firm. She tells you that a month ago she
was 135lbs but when came to the ER she was only 128 lbs. You ask
her why she thinks she has lost weight and she says, "I haven't
eaten well since I started to get sick almost 2 weeks ago. I
haven't had an appetite and it takes a lot of effort to eat due to
my shortness of breath." Linda eats a low cholesterol, regular diet
at home.
Her bloodwork showed a WBC is 16.2 and her CXR shows
consolidation to the left lower lung.
Nursing Care Plan Part 2 (10%)
Worksheet
* Nursing diagnosis/problem
* 1 short term SMART goal/expected outcome
* 4 nursing interventions with cited rationale
* Evaluation
1.Nursing Diagnosis/Problem: Review the priority cluster
and select the priority nursing
diagnosis/problem.
2. List the signs and symptoms from your data collection
that support the chosen diagnosis/problem.
1)
2)
3)
4)
5)
3. Priority Nursing Diagnosis/Problem
Statement:
4. Short Term SMART Goal/Expected Outcome:
5. Nursing Interventions:
6. Identify four appropriate Nursing Interventions with
cited rationale
7. Evaluation: Because you cannot truly evaluate the
outcomes it will be important to provide an explanation about what,
when and how would you evaluate the nursing
interventions.
8. final care plan on the template below
Nursing Care Plan Part 2 Template
nursing care about the respiratory. Please help me.
Linda Cerullo is a 56-year-old female who was brought to the
hospital by ambulance on January 25, 2021. She presented to
the emergency department and was diagnosed with left sided
bacterial pneumonia. She has a history of iron deficiency,
high cholesterol and hypertension. Past surgical history
includes a caesarian section. She is taking ramipril 10mg PO,
daily, atorvastatin 20 mg PO, daily and ferrous fumarate, 300 mg,
PO BID. She has an IV of 2/3 & 1/3 running at TKVO in her
left hand and is currently on IV ceftriaxone 1gm q24 hours plus
Tylenol 1g, PO q6H prn for fever or pain. Linda is currently
a secretary at a dental office. She lives at home with her husband
and her adult daughter. She is Italian by birth and attends
Roman Catholic mass weekly. At home the family speaks Italian but
she is fluent in English. She is a full code status and has
allergies to penicillin and vancomycin. Linda wears reading
glasses.
Today is the second day of her admission and you are the nurse
caring for her on the medical unit. Upon your assessment her vital
signs are temp 38.9 degrees Celsius, pulse (radial) 99 beats/min,
RR 24/min, BP 118/79 and O2 sat 92% on 2L of oxygen via nasal
prongs. You use your stethoscope to auscultate her chest and
note decreased breath sounds to the LLL. She has a productive
cough still and complains of being short of breath frequently.
You ask her to sit up in the bed and notice that she becomes
increasingly short of breath with bed mobilization. There is
evidence of accessory muscle use (abdominal breathing).
When asked if she has any pain the patient states "Yes I have
pain when I breathe deeply or cough." She rates her pain as 2/10 at
rest and 6/10 when breathing deeply or coughing. You ask
Linda when she first noticed the pain, "I first noticed the pain at
5am today". Linda explains to you that she is feeling "unwell
and tired". She expresses frustration with her inability to
sleep due to noise in the hallway at night. She also reports
difficulty in getting into a comfortable position to rest as she
normally sleeps on her side at home but gets very short of breath
when lying down now. You notice she is short of breath during the
interview. She can get no more than two words out before
having to stop talking and rest.
You compare that to the blood pressure that the previous nurse
had obtained overnight from the patient. Her blood pressure
overnight was 99/69. You recognize that this was lower than
normal and ask her if she gets dizzy or lightheaded. She tells you
that she is not now but sometimes when she gets up suddenly she
does get dizzy and lightheaded.
Linda also expresses frustration to you about being constipated,
"I think I need some bran flakes. I haven't had a bowel
movement in 2 days". She says that her medication makes her
constipated but at home she is active and drinks more fluid to
assist with this. Her abdomen does appear distended. You auscultate
for bowel sounds and note that they are hypoactive in all 4
quadrants. You palpate all four of her abdominal quadrants and note
they are slightly firm. She tells you that a month ago she
was 135lbs but when came to the ER she was only 128 lbs. You ask
her why she thinks she has lost weight and she says, "I haven't
eaten well since I started to get sick almost 2 weeks ago. I
haven't had an appetite and it takes a lot of effort to eat due to
my shortness of breath." Linda eats a low cholesterol, regular diet
at home.
Her bloodwork showed a WBC is 16.2 and her CXR shows
consolidation to the left lower lung.
Nursing Care Plan Part 2 (10%)
Worksheet
* Nursing diagnosis/problem
* 1 short term SMART goal/expected outcome
* 4 nursing interventions with cited rationale
* Evaluation
1.Nursing Diagnosis/Problem: Review the priority cluster
and select the priority nursing
diagnosis/problem.
2. List the signs and symptoms from your data collection
that support the chosen diagnosis/problem.
1)
2)
3)
4)
5)
3. Priority Nursing Diagnosis/Problem
Statement:
4. Short Term SMART Goal/Expected Outcome:
5. Nursing Interventions:
6. Identify four appropriate Nursing Interventions with
cited rationale
7. Evaluation: Because you cannot truly evaluate the
outcomes it will be important to provide an explanation about what,
when and how would you evaluate the nursing
interventions.
8. final care plan on the template below
Nursing Care Plan Part 2 Template