Question: Assessment Collection Of Subjective & Objective Data Data Analysis Cluster Data Together To Determine What Are The Priority Problems) Nursing Diagnosis (NANDA) Determine The Priority Problems Of The Patient And Write One Physiological And One Psychosocial Nursing Diagnosis—(based On What You Have Determined To Priority Problems) Must Have Three Parts …

Assessment

Collection of Subjective &

Objective data

Data Analysis

Cluster data together to determine what are the priorityproblems)

Nursing Diagnosis (NANDA)

Determine the priority problems of the patient and write onephysiological and one psychosocial nursing diagnosis—(based on whatyou have determined to priority problems)

Must have three parts 1. (NANDA appropriate diagnosis 2. relatedto (etiology)

3. as evidenced by (data to support the nursing diagnosis)

Planning (SMART goals)

(one goal for each nursing diagnosis)

Use SMART criteria to create goals

Interventions

List 5 priority nursing interventions for each nursingdiagnosis

Rationale for Interventions

Explain the reason for each intervention (why are youimplementing the intervention?)

Evaluation

(what will you be evaluating for? What are you expecting to thebe outcome for each intervention?)

-Presented with COPD exacerbation

-age: 55 years old

-smoker

– For her COPD, she normally takes budesonide/formoterolcombination (160 mcg/4.5 mcg), 1 pump 4 times daily as needed

– she has been taking the maximum daily allotment ofipratroprium/albuterol for the last 3 days

-Provider’s orders: Provide O2 at 2L per minute via nasalcannula (NC). Keep SpO2 between 88%- and 92%. Keep patient on herbudesonide/formoterol combination (160 mcg/ 4.5 mcg), 2 pumps 2times daily, every 12 hours. Administer 40mg of prednisone, PO 1time per day for 5 days. Record vitals and monitor mental statusevery hour

-four days ago, the patient began experiencing shortness ofbreath and increased coughing. Originally thought it was a cold butit worsened after several days.

-coughing prevented sleep, then coughing developed intowheezing

-sputum went from tan to green

-yesterday, she experienced frequent SOB and relentlesscough

-Her daughter, Ava, brought her into ER at 1600h

Objective:

-diagnosed with COPD exacerbation

-experiences dyspnea on exertion

-relentless, wheezing cough that produces green sputum

-RR:28 per minute

-ABG’s from admission are as follows: on room air uponadmission, pH was 7.36, PaCo2 was 48 mmHg, HCO3 was 24 mEq/L, andPaO2 was 62 mmHg

-O2 sat: 89% on 2L O2

-temp: 37.2 C

-BP: 128/82 mmHg

-HR: 92 bpm

-RR: 28

-O2 sat: 89 on 2L O2

-PAIN: 0/10

-Intake: oral fluids

-Output: >30 ml/hr

Recommendation: I recommend that you closely monitor thepatient’s vital signs and oxygen saturation. Notify the decision ifthe oxygen saturation drops below 88%. Regularly also tape testsound and check mental status. Energy conservation education andanxiety management.

Time has passed:

-the patient is in a guarded condition. It is important tocontinue monitoring her vital signs and oxygen saturation. Hervitals were taken 30 minutes ago and her 02 sat at that time was89%