Step 1 Read the case to formulate a priority nursing diagnosis Step 2 Describe why you chose that diagnosis you did and
Posted: Mon Jul 11, 2022 2:26 pm
Step 1 Read the case to formulate a priority nursingdiagnosis
Step 2 Describe why you chose that diagnosis you did and thereason behind it (include cluster data support, method ofprioritization, and Maslow hierarchy)
Mrs. K is a 68-year-old woman who presented to the emergencydepartment with shortness of breath. She is unable to walk to hermailbox without becoming very winded.
Her assessment is as follows:
Neuro: A&O x 4, anxious
Cardiac: HR 105 bpm, bounding pulse, jugular venous distention(JVD),
Respiratory: crackles, dry cough, dyspnea on exertion (DOE)
GI: BS normoactive in all 4 quadrants, LBM yesterday
GU: decreased urine output
Peripheral/neurovascular: +3 pitting edema in bilateral lowerextremities
Vitals:
T: 98.2 Oral
HR: 105 bpm apically
RR: 24
POX: 87% on RA, 93% on 2LPM nasal cannula
BP: 143/89 left arm
Weight: 185 lb (last visit to PCP in September she was 176lb)
Labs:
Na: 130 mEq/L
K: 3.6 mEq/L
Mg: 2.2 mEq/L
Cl: 100 mEq/L Ca: 8.6 mEq/L
She was diagnosed with heart failure and admitted to themed/Surg unit.
Step 2 Describe why you chose that diagnosis you did and thereason behind it (include cluster data support, method ofprioritization, and Maslow hierarchy)
Mrs. K is a 68-year-old woman who presented to the emergencydepartment with shortness of breath. She is unable to walk to hermailbox without becoming very winded.
Her assessment is as follows:
Neuro: A&O x 4, anxious
Cardiac: HR 105 bpm, bounding pulse, jugular venous distention(JVD),
Respiratory: crackles, dry cough, dyspnea on exertion (DOE)
GI: BS normoactive in all 4 quadrants, LBM yesterday
GU: decreased urine output
Peripheral/neurovascular: +3 pitting edema in bilateral lowerextremities
Vitals:
T: 98.2 Oral
HR: 105 bpm apically
RR: 24
POX: 87% on RA, 93% on 2LPM nasal cannula
BP: 143/89 left arm
Weight: 185 lb (last visit to PCP in September she was 176lb)
Labs:
Na: 130 mEq/L
K: 3.6 mEq/L
Mg: 2.2 mEq/L
Cl: 100 mEq/L Ca: 8.6 mEq/L
She was diagnosed with heart failure and admitted to themed/Surg unit.