2. Identify the possible client complications associated with tube feedings.
3. Explain the correlation between nitrogen balance and nutritional status.
4. Discuss the nursing considerations necessary to safely administer medications through a
Mr. L. Stevens, age 80, has been admitted to the medical unit in acute distress. His respirations are
labored and he is verylethargic. He has been a resident of the Creek View skilled nursing facility
(SNF) for the past 10 months. He had previously lived with his niece until she became concerned
that he could no longer be left alone while she was working. Mr. Stevens\u2019s admitting diagnosis is
right upper lobe (RUL)pneumonia. The transfer notes from the SNF indicate that he has had little
or no appetite for the past 2 weeks. His fluid intake for the past few days has consisted of
occasional sips of apple juice. During the admission process, the nurse noticed that he isdyspneic
andemaciated. Shortly after his admission to the unit, his niece arrived and informed the nurse that
Mr. Stevens had developed a chest cold about 2 weeks ago and that the cold seemed worse each
time she visited him. He has been bedridden for most of the past week. The niece stated that she
knew he was sick when he refused to eat his favorite rice pudding that she made especially for him.
SNF today. Assessment of the respiratory system foundcrackles on the right side, a cough
producingtenacious, green sputum, and +3 pitting ankle and sacral edema. Vital signs are T 99.6\u00ba
F, P 92 and weak, R 24 and shallow, BP 128/72. Physician\u2019s notes state that Mr. Stevens is
manifesting a negative nitrogen balance and orders the following: start O2 at 4L/NC (nasal
On the morning of the third day, Mr. Stevens\u2019s dyspnea is slightly improved, with crackles still
audible, and ankle edema +2. The tube feeding was increased to 75 ml/hr. Later that evening Mr.
Stevens began withdiarrhea and the nurse found the feeding tube kinked and infusion pump turned
Based on the data in the case study for Mr. Stevens, what problem/nursing diagnosis do
you wish to address first? Choose the three nursing diagnoses with the highest priority.
RUL pneumonia and assessed as having a productive cough with copious secretions. The client is also dyspneic and emaciated. These factors contribute to the client\u2019s inability to effectively clear his secretions from the respiratory tract and can lead to impaired gas exchange in the lower airways.
Proper nutritional intake is necessary for maintenance of basic life processes, as
well as the ability to fight disease and infection. Depending on the level of physical
activity, a healthy person requires 2000 to 3000calories/day. Most standard
formulas range from 1 to 2 calories/ml and supply a percentage of protein, fat, and
Weight measurement provides an indication of the amount of body fluid retained or loss for a client on diuretic therapy. A loss of 2 pounds over a day or less indicates a loss of approximately 1 L of fluid.
Edematous areas are prone to skin breakdown. Frequent assessment of skin helps
promote early nursing intervention to prevent skin breakdown. Elevation of the
edematous extremities facilitates venous return, decreasing cardiac workload.
Based on data for Mr. Stevens, the nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements, and the expected outcomes you have identified, which actions would you take?
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