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Student Name: Gloria Gonzalez Client Initials: T. L.

Age: 79

Sex: M

Clinical Site: Diet: 1600 calorie Diabetic diet

Date Submitted: 4/5/2011 Clinical Week: 2nd week

NURS 2413 Basic Skills of Nursing Admitting Diagnosis: Squamous Lung Cell Carcinoma
NURSING DIAGNOSIS

DATA COLLECTION SUBJECTIVE: (What is said by client, facts) -Complained of shortness of breath - Shallow breathing (sighness) - Pain in chest area OBJECTIVE: (Data that is measurable or observable, from history, physical assessment, lab results, test results, and medications) -82 SpO2 with 3L of O2 via nasal cannula - Respiratory rate at 18 with irregular breating patterns - History of lung cancer - Left upper lobectomy 3/23/2011 - Spirometer out of range - Chest tubes to drain fluids from lungs

THEORIST (Discuss as it applies to your client) NURSING: Henderson- 1955 - “ Work independently with other health care workers, assisting client in gaining independence as quickly as possible; to help client gain lacking strength” (Potter and Perry, pp.49). - Clients current needs: • • • breathe move eliminate wastes

1. NANDA LABEL (actual or potential) - Impaired gas exchange - Risk for activity intolerance - Constipation RELATED TO - Insufficient oxygen intake - Abnormal breathing patterns

AS EVIDENCE BY: (casual factors must be amendable to nursing interventions) - Shallow breathing - Pulse oximetry

GOAL AND OUTCOMES GOAL: (Realistic for client and a SHORT TERM goal and TIMED) - Patient performing ADL without exacerbate breathing patterns/ increasing pulse oximetry level OUTCOMES: (Use measurable and observable terms) 1. Pulse oximetry is at 90 or improved after ADL

PLANNING IMPLEMENTATION/ NURSING ACTION (Highlight nursing orders actually performed) NURSING OBSERVATIONS (What will you monitor assess, or reassess): - Use pulse oximetry to monitor oxygen saturation - Assess skin color for development of cyanosis - Monitor vital signs - Assess lung sounds - Assess respirations NURSING INTERVENTIONS: (dependent, independent) - Maintain oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater - Position with proper body alignment - Encourage deep breathing, using spirometer - Encourage or assist with ambulation CLIENT OR FAMILY TEACHING: - Explain the type of oxygen therapy being used and why its maintenance is important

RATIONALE AND REFERENCES (Principles of nursing interventions are explained scientifically, and supports each order identified and provides source used) WHY! -Maintaining oxygen administration provides for adequate oxygenation - Proper positioning promotes lung expansion and improves air exchange - Encouraging deep breathing will assist with lung expansion - Assistance with ambulation promotes lung expansion, facilitates secretion clearance, and stimulates deep breathing

EVALUATION Goal Met - Partially Met - Not Met GOAL: _________MET_______________(reassess each outcome criteria identified under goal) 1. ADL were performed without interference of oxygen saturation (95)kept at a stable breathing pattern

Potter, P.A. & Perry, A.G. (2009). Fundamentals of Nursing 7th ed. St. Louis, Missouri: Elsevier.

heartburn. flatulence. Respiratory depression Hypotension. nausea Hypoglycemia. output ratio 12hr fasting lipid profile Hepatic studies Absence of nausea. Missouri: Elsevier. . Abdominal cramping Dizziness. constipation Headache. Na. electrolyte balance. hyperosmolarity. parenteral solution Potter. Fundamentals of Nursing 7th ed.G. Renal studies. electrolyte balance. rectal bleeding. Cl.Definition of the Medical Diagnosis: Signs and Symptoms Associated with Condition: complained shortness of breath. hypokalemia Hypovolemia. Urticaria. Blood studies Cramping. Mg) balance. Gastrointestinal hemorrhage Upper respiratory infection.A. (2009). shallow breathing List ALL Diagnostic Test Results Lab or Imaging Results (Normal / Abnormal) Normal Rationale for MD orders related to client’s diagnosis Improves blood flow Medication Identify ALL Medication (Include IV solutions and any PRN’s for the assigned client) Classification Action Dosage Rationale (Relate to client’s condition) Hx of open heart surgery Adverse Reactions (List Most Common) Nausea. constipation pneumonia Hypotension. rashes Weight. phlebitis Monitor temperature. Rash. Rash. blood glucose Hemoglobin Abnormal Oxygen level Stool softener H2-histamine receptor antagonist Antacid/Laxative Constipation Short term treatment of active duodenal ulcer Constipation Hematocrit Lymphocyte Abnormal Abnormal Blood consisting red blood cell count Immune responses WBC Abnormal Blood consisting of white blood cells Balance of electrolytes Potassiumsparing diuretic Nonpioid. constipation. Louis. Analgesic Antipyretic Antilipidemic Constipation Sodium Abnormal Block pait impulses Control elevated cholesterol levels Prevention of nausea To drop glucose levels Insulin Increases intake of calories Pain Calcium Normal Help blood vessels and muscles contract Blood consisting of red blood cells Diabetic High Cholesterol levels Prior to induction of ansethesia Increase fluid retention Diabetic Diabetics RBC Abnormal Antiemetic Glucose Abnormal Antidiabetic Chloride BUN Normal Normal Balance of electrolytes Edema/ CHF Levemir Flexpen Dextrose Glucose Insulin detemir Caloric. rashes Hepatic studies renal blood & input. diarrhea Hypoglycemia. Antagonist 30mL U/D Daily 25mg/ 1cap Daily 500mg 1000mg/2tab PRN 20mg/ 1tab Bedtime 4mg/ 2mL Q8hrs PRN 5mg/ 1tab TID 20units/ 0. A. St. Vomiting Excessive bowel activity. blood glucose Major Nursing Implication Potassium Aspirin Acetylsalicylic acid Docusate Sodium Dulcolax Stool Softener Famotidine Pepcid Milk of Magnesia susp Triamterene Dyrenium Acetaminophen Tylenol Simvastatin Zocor Ondansetron Zofran glyBuride Nonopioid analgesic Prevention of recurrent MI Prevention of dry. hypersensitivity reaction Hypo/hyperglycemic reaction. Hepatic studies. Hyperuricemia Disorientation. & Perry. Fever. hard stools Decrease gastric secretion Relieve of indigestion and heartburn Edema 81mg/ 1tab Daily 100mg/ 1cap q12hrs H2 Histamine Receptor. Ca. Fatigue. P.2mL Bedtime 25gm/ 50mL PRN Pain. electrolytes (K. vomitting Blood count test (look for decreasing platelets) Weight. insulin resistance.