The RN is developing a plan of care for a 78-year-old patient who was admitted f
ID: 122554 • Letter: T
Question
The RN is developing a plan of care for a 78-year-old patient who was admitted from home with a medical diagnosis of pneumonia and dehydration. Medical orders read: out of bed 3 times a day, oxygen 2 liters nasal cannula, and regular diet as tolerated. The patient’s vital signs are temperature 100.8° F, heart rate 88 respiratory rate 18, B/P 100/68, pulse oximetry 91%. The patient has tenting at the clavicle. The patient has a productive cough with green-yellow sputum and is short of breath with all activities. An intravenous infusion of normal saline is infusing at 100 mL per hour. The chest x ray shows consolidation in the bases. The RN has included the following NANDA-I nursing diagnoses in the plan of care: Ineffective airway clearance Activity intolerance Deficient fluid volume
Explanation / Answer
The first phase of the diagnosis is medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures. The second phase of the nursing process is nursing diagnosis. It is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Ex: acute pain, nausea
North American Nursing Diagnosis Association International (NANDA-I) known for its identification of over 235 nursing diagnoses in new 2015-2017 updated edition. It divides diagnosis nursing diagnoses into four categories: actual diagnosis, risk diagnosis, health promotion diagnosis and syndrome diagnosis. According to the NANDA-1 risk diagnoses the old patient had a symptoms like a productive cough with green yellow sputum, shortness of breath, temperature of 100.8 F, BP 100/68 and pulse oximetry 91%. The chest x ray shows consolidation in the bases. So the patient was suffering from pneumonia and dehydration because shortness of breath, fever and low blood pressure, greenish yellow sputum and basal consolidation.
The RN has included the following NANDA-1 nursing diagnosis in the plan of care: Impaired gas exchange, Ineffective airway clearance, Activity intolerance and Deficient fluid volume. This attention to detail could be the difference between the correct treatment and continued illness or injury. A nursing diagnosis is a statement indicating several different potential problems a patient may face. A nurse will diagnose and treat the symptoms or health problems, and a nursing diagnosis is the groundwork for establishing and carrying out a patient care plan.
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