University:
University of North Carolina at Chapel Hill
Course:
NURS 110 | Introduction to Nursing
Academic year:

2020
Views:

496

Pages:

1
Author:

Bidoggia5pt

List all scheduled medications (dose, rationale, S/E) on back - 20 pts Evaluate (Was the goal met or unmet?) - 5 pts Improved lung sounds, Goal was met O2 sat increased from 85% to 94%. Goal met. Implementation (How will you meet your goal?) - 20 pts 1. Ensure pt is receiving dialysis. 2. Monitor lung sounds and vitals. 3. Admin O2 as ordered. 4. Admin pain meds as ordered. Goal (Specific, Measurable, Attainable, Relevant & Timely) - 5 pts By 24 hours, lung sounds will improve and O2 saturation will be over 90%. Priority Nursing Diagnosis - 15 pts Problem: Impaired Gas exchange R/T Collection of fluid in lungs and decreased O2 sats AEB Pulse Ox low, diminished breath sounds, & ultrasound of lungs. Interdisciplinary Care (Which department and what do they do for pt) - 5 pts Respiratory therapy Dialysis, technician provides dialysis. Nutrition provides modified diet specific to patient. What concept are you focusing on and give reasons why patient came to the facility. Gas exchange. Interrelated Concepts & Rationale - 10 pts 1. Perfusion 2. Fluid & Electrolytes Signs/Symptoms (Assessment) - 10 pts Diminished lung sounds O2 sats low History of Kidney Failure Pain while breathing Ultrasound showed lungs (pleural space) has fluid in them. Medical History (for Risk Factors) - 5 pts If there is a relationship with medical history and problem, identify and explain. Kidney failure patient was unable to rid body of fluid, fluid started collecting in pleural space in lungs. We fixed her fluid & electrolytes, lab values and lung function improved. Diagnostic Studies (Lab/XR) & Explanation (provide rationale for altered levels) - 10 pts CBC to get blood info. Ultrasound of lungs to look & prove fluid is present. XRay of lungs to rule out other things.