Question:
The RN is preparing a plan of care to treat a 78-year old patient.
Tinting at the clavicle.
a. Identify the data you will use to support one of your chosen Nursing diagnoses. Write three parts for the nursing diagnosis statements you have selected. Give a time frame and a measurable outcome for this patient. Also, explain why you chose the nursing diagnoses.
Answer to Question: NUR3029 Fundamental In Nursing
Introduction
This paper focuses on the case of a 78-year old patient who was admitted from his home with a diagnosis of pneumonia.
The patient is required to get out of bed as often as possible and must be fed regular food.
The patient must receive oxygen 2LPM via a nasal canula.
The vital sign report shows temperature of 100.8 F with 88 heart beat, 18 respiratory rate, and BP100/68. Oxygen saturation is 91%. There is tenting around the clavicle.
Reports have been made that the patent was associated with a productive cough, green-yellow sputum, and heart rate 88.
The NANDA nursing diagnosis “Deficient Fluid Volume” will be the focus of this paper.
Nursing Diagnosis
Ineffective airway clearance and activity intolerance are the three possible nursing diagnoses in this case.
Fluid deficient volume is our chosen nursing diagnosis.
Nursing Three-Part Diagnosis Statement – Deficient of Fluid Volume
Fluid volume problems due to dehydration can be seen in the patient’s excess fluid loss, which is caused by the vomiting, urination. fever, shortness and high blood pressure.
The patient is now unable to tolerate certain foods and has been requiring three trips to the bathroom daily.
The literature supporting the diagnosis is used to provide evidence and it is discussed in the following sections.
Arguments
The case report of the patient shows that the patient suffered from pneumonia and is dehydrated.
Gathara, et.al.
According to Gathara et. al. (2013), these factors can lead to increased dehydration.
The following case study has highlighted the symptoms.
When a patient has pneumonia, they have a low oxygen level. They require oxygen until the condition clears.
Pneumonia can lead to dehydration due to fever, reduced appetite and thirst.
Fever can increase the metabolic rate, which causes fluid loss through evaporation.
Below is the nursing plan for this patient. It uses SMART framework.
This Specific Plan of Action (Davis (2015)) can be used to help you gain your goals.
Regular assessments of vital signs are important to ensure that you don’t become dehydrated.
Regular assessments of skin turgor & mucous membrane moisture are important indicators of the fluid volume.
Note the frequency of nausea/vomiting as indicated by oral input
Collaboration of the antipyretics, and anti-emetics because they are useful in decreasing fluid losses
The measurable outcome is the patient showing adequate fluid volume after assessment (Gathara et. al., 2013,).
These objectives are achievable by toe nurses as per their scope of practice. The nursing goals are relevant to deficient fluid volume.
Time frame – A 24-hour assessment is possible to reduce vomiting.
In this case, the fluid deficit can only be half in 24 hours.
Within 48 to 72 hours, any remaining fluid can be replaced.
A fever may be reduced in as little as 24 hours.
The patient’s response in the next 24 hours can adjust the intervention (Rabelo_Silva, 2017).
ReferencesDavis, H. (2015). Nursing care.
Veterinary Clinics Small Animal Practice, 45(5) 1029-1048Gathara, D., Irimu, G., Kihara, H., Maina, C., Mbori-Ngacha, D., Mwangi, J., … & English, M. (2013).
Hospital outcomes for paediatric patients with diarrhoea or pneumonia admitted to a hospital on weekdays: A retrospective study.
BMC pediatrics, 13(1) 74.Rabelo?Silva, E. R., Dantas Cavalcanti, A. C., Ramos Goulart Caldas, M. C., Lucena, A. D. F., Almeida, M. D. A., Linch, G. F. D. C., … & Muller?Staub, M. (2017).
Advanced Nursing Process quality: Comparing NANDA?International (NANDA?I), and Nursing Interventions Classifications Classifications (NIC).
Journal of clinical nurses, 26(3-4), 375-387.Simonetti, A. F., Viasus, D., Garcia-Vidal, C., & Carratala, J. (2014).
Management of community-acquired pulmonary disease in older adults.
Therapeutic advances for infectious disease, 2(1). 3-16.