NUR3029 Fundamental In Nursing

Question:

Tinting at the clavicle. The RN is creating a plan for care for a 78-year-old patient.

Tinting around the clavicle.

a) Identify the relevant data that you will cluster to support the Nursing diagnoses chosen Write a three-part nursing diagnosis statement for the Nursing diagnoses selected Write a measurable Outcome with a time frame and a reason for the nursing diagnoses chosen

Answer:

Introduction

This paper examines the case of a 78 year-old patient admitted to hospital with a medical condition of pneumonia and dehydration.

According to the handover information, the patient must be out of bed at least three times per day and be fed a regular diet.

The patient should be given oxygen 2LPM per nasal tube.

Vital sign reports show temperature of 100.8 F, heart beat 88, respiratory rate 18 and BP100/68. There is oxygen saturation of 91%. The patient has tenting at their clavicle.

Reports indicate that the patent had a productive cough and green-yellow sputum.

This paper will be about the NANDA nursing diagnosis of “deficient in fluid volume”.

Nursing Diagnosis

These three nursing diagnoses are: ineffective airway clearance; activity intolerance; and deficient fluid volume.

Fluid deficient volume is the chosen nursing diagnosis.

Deficient of Fluid Volume- Nursing Three Part Diagnosis Statement

Fluid volume deficiencies due to dehydration are evident in excessive fluid loss caused by vomiting, urination and fever.

The patient is unable to tolerate food prescribed by his physician. He is unable to get out of bed at least three times per day.

This section discusses the evidence that is available to support the diagnosis.

Rationale

The case study of the patient reveals that the patient had pneumonia and was dehydrated.

Gathara and colleagues.

Gathara et al. (2013) state that vomiting, diarrhoea and rapid breathing are all factors that can increase dehydration.

The above-mentioned symptoms were evident in the case study.

The patient with pneumonia has a low oxygen level, and must be oxygenated until it is gone.

In pneumonia, dehydration can occur due to fever, decreased appetite, and thirst. Extra fluids must be administered intravenously (Simonetti, et al. 2014).

Evaporation occurs when fluid is lost due to fever.

This nursing plan is based on the SMART framework. It can be found below.

This is the specific plan of action (Davis 2015) that you need to follow in order to achieve this goal.

Regular monitoring of vital signs is important as an increase in temperature can increase dehydration.

Regular evaluation of skin turgor and mucous membrane moisture is important as these indicate the fluid volume strength.

Take note of the frequency of nausea or vomiting, as indicated by the oral input

Collaboration of the anti-emetics and antipyretics, as they are helpful in decreasing fluid loss

The patient’s ability to demonstrate adequate fluid volume at assessment is the measurable outcome (Gathara and co., 2013).

These goals can be attained by the toe nurse according to the scope of practice.

Time frame – This assessment can be completed within 24 hours, which would decrease vomiting.

This case study shows that half of the fluid loss can be restored within 24 hours.

In 48 to 72 hours, the fluid loss can be replenished.

Within 24 hours, the fever can be decreased.

The patient’s response can be modified as needed (Rabelo?Silva and co., 2017).

Refer to

Veterinary Clinics for Small Animal Practice, 45(5): 1029-1048.

Hospital outcomes for diarrhoea and paediatric pneumonia patients admitted to a tertiary institution on weekdays versus weekends: A retrospective study.

BMC Pediatrics, 13(1): 74.

Advanced Nursing Process quality: Comparison of the International Classification for Nursing Practice, (ICNP), and the Nursing Interventions Classifications (NIC)

Journal of clinical nursing 26(3)-4, 379-387.

Management of community-acquired pneumocolitis in older adults.

Therapeutic advances in infectious diseases, 2(1): 3-16.

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