Assignment 4

Case Study The patient is an elderly man who appears tired haggard and underweight.
His complexion is sallow. He coughs continuously. Sitting in a chair, he leans to his right
side, holding his right chest with his left arm. Vital signs are as follows: blood pressure
152/90, apical heart rate 112/minute and regular, respiratory rate 24/minute and
somewhat labored, temperature 102.6F. Examination of the neck reveals a large, non-
tender hard lymph node in the right supraclavicular fossa. Both lungs are resonant by
percussion with one exception: the right mid-anterior and right mid-lateral lung fields are
dull. Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath
sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-
anterior and right mid-lateral lung fields. The remainder of the lung fields is clear.
Percussion and auscultation of the heart reveals no significant abnormality. Examination
of the fingers shows clubbing. Create a sample Nursing Care Plan for this case.

Nursing Care Plan

Assessment Diagnosis Outcomes Interventions Rationale Evaluation

Subjective: - Ineffective - The - Assess the - To identify - The patient

(none) airway patient will rhythm, and severity was able to
Objective clearance, maintain depth of - To make maintain
- Appears tired production airway respiration, sure that the patent airway
haggard and AEB patency and chest patient has with breath
underweight coughing expectorate movement and the ability to sounds
- Complexion and based secretions use of maintain his clearing AEB
is sallow on his readily accessory breathing and
- Coughs laboratory muscles. pattern. effectively
continuously examination - Assess level - To relax clearing
- Holding his it could be of smooth secretions.
right chest with asthma consciousness respiratory
his left arm chronic / musculature
- BP 152/90 obstructive cognition and , reduce
- Apical heart pulmonary ability to airway
rate disease or protect own edema, and
112/minute Bronchogeni airway. mobilize
and regular c Carcinoma - Administer secretions.
- RR 24/minute - Edema medications
and somewhat formation such as
labored - Increased expectorants,
- T 102.6 F soutum anti-
- neck reveals inflammatory
a large, non- agents,
tender hard bronchodilator
lymph node in s, and
the right mucolytic
supraclavicular gents, as
fossa indicated.
- the right mid-
anterior and
right mid-
lateral lung
fields are dull
- The
remainder of
the lung fields
is clear.
- Percussion
and
auscultation of
the heart
reveals no
significant
abnormality.
- Examination
of the fingers
shows
clubbing.