Identify 5 nursing diagnosis relevant for this client.
Identify 5 nursing diagnosis relevant for this client.
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Instructions to Students:
Students completing this assessment will need to achieve a minimum of 50% to pass. In the event a pass is not achieved you will be given one opportunity to resubmit your worksheet within 2 weeks from when you are notified of your result. The maximum marks allowed for a 2nd attempt will be 50%, if you are unsuccessful in achieving 50% with the resubmission you will need to repeat the entire unit.
Identify 5 nursing diagnosis relevant for this client. For diagnosis document and explain 3 nursing interventions, plus a rationale for each intervention. Include in you management plan the medications as listed including their actions and intended therapeutic outcomes along with the nursing management and monitoring of the medication effects
Reasonable Adjustment
We recognise the need to make reasonable adjustment within our assessment and learning environments to meet your individual needs. If you need to speak confidentially to someone about your individual needs, please contact your unit lecturer or senior educator.
Patient history:
75 yr old male, admitted with 3 day history of Fatigue and sob, over last 2 months has found it difficult to sleep has begun sleeping with head elevated on 2 pillows, denies having any chest pain during this time.
Ph, CCF, HT, Unstable angina CABG x2 2012, type II diabetes, Obs: RR 20 PO2 93%, BP 118/74 PR 86 irregular T 36.5
Smoker 1 pkt/day for 45years ex-smoker for 15 years IV cannula Left arm, 6/24 N/S Flushes ECG- ST elevation leads II, III, AVF
Medications
Lasix 40mg bd given 40 mg IV in Emergency oral dose increased to 80 mg bd 0800 and 1200 GTN 25mg patch on 0800 off 2200
Ventolin Qid PRN Enalapril 10mg daily Amlodapine10 mg daily
Cartia 100mg daily Warfarin 4mg daily Daonil 10mg daily
Anginine SL PRN Morphine 2.5mg-5mg IV PRN
Management
1.5 FR, daily weight, strict FBC, QID BGL, 4/24 observations, O2 2L prn, ECG 6/24
Nursing Diagnosis Nursing Intervention Rationale Expected Outcomes
Pain Discomfort
Difficulty breathing related to
Impaired gas exchange related to
Nursing Diagnosis Nursing Intervention Rationale Expected Outcomes
Risk of Reduced mobility related to
Risk of poor nutrition related to
Risk of skin breakdown related to
Nursing Diagnosis Nursing Intervention Rationale Expected Outcomes
Inability to maintain personal hygiene
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