Reference no: EM133656286
The nurse is caring for Oliva Jamison, 77 years old, and was admitted to the medical unit with exacerbation of COPD. vital signs upon admission to the unit is: Blood Pressure 156/88, pulse 101; Respiration Rate 28, Temperature 97.8. The client reports worsening shortness of breath, extreme fatigue, decreased appetite, and a weight loss of 15 pounds over the past three months. The nurse notices the client is lying flat in bed and currently on 2L O2 via nasal cannula with an oxygen saturation level of 88%. Other symptoms include a dry cough, inspiratory and expiratory wheezes upon auscultation of breath sounds. Respiratory treatments ( albuterol ) are ordered every 4 hr as needed. The client reports having little or no family support.
1. Identify the relevant subjective and objective assessment information related to the client's condition and place the findings in the assessment data box below ( recognizing cues, assessment ).
2. Based upon assessment information, identify and prioritize the top 3 client problems. write one client problem in each of the client problem boxes below ( analyze cues; Analysis and prioritize Hypothesis; Planning ).
3. Below each client problem, determine and enter the relevant assessment information that supports the identified client problem ( Analyzes cues; Analysis and prioritize Hypothesis; Planning ).
4. Identify important nursing interventions that should be taken to address each client problem and enter them in the related intervention box for the associated client problem. ( Take Action; Implementation ).