Directions: Sort the items into the appropriate categories:

Question Answered step-by-step Directions: Sort the items into the appropriate categories:Categories are: Subjective Data, Objective Data, Problem, Etiology r/t, Signs & Symptoms/Defining Characteristics, Nursing Diagnosis (in one Statement), Goal: Pt will… , Outcome Criteria, Nursing Actions, Goal met; partially met; unmet?, and Outcome CriteriaItems:· Nursing Actions· 1000 mL D51/2 Normal Saline @ 75 mL/hour· Elevate HOB 45- 60 degrees· 92 yo white female admitted on 6/6/20 with Pneumonia· Cough productive of moderate amount of yellow sputum· Change patient position q2hours· Dyspnea (difficulty breathing)· Assist client with deep breathing exercises· Circumoral cyanosis· Suction as indicated· Risk for ineffective airway clearance· Fluids as ordered (po & IV) to 3000 mL/24 hours· r/t· Oral temp: 102 F· inability to cough up secretions· Goal met· Administer O2 @ 2L via nasal cannula, as ordered· No accessory muscles used to assist breathing· Monitor chest x-rays, ABGs, pulse oximetry (>92%) as ordered· Oral temperature 98.6 F on 6/8/20 @ 8 AM· Clear breath sounds on 6/8/20 @ 8 AM· RN to assess rate & depth of respirations q 3-4 hours· RN to auscultate lung fields for adventitious breath sounds, e.g., crackles, wheezes· Respiratory rate on 6/8/20: 12 – 16 breaths/minute· Assessment Nursing Diagnosis Plan Interventions Evaluation· Abnormal breath sounds: crackles in both lung fields· Regular diet as tolerated; feed as necessary· Outcome Criteria:Respiratory rateDyspneaCyanosisUse of accessory musclesCough effectivenessSputum productionBreath SoundsTemperature [Oral]· Evaluation· Goal:Pt will demonstrate clear breath sounds on day 2 post-admission· Objective Data· “I feel hot and congested”· Respiratory rate: 24 breaths per minute· Use of accessory muscles to breathe· Administer meds as ordered:mucolyticsexpectorantsbronchodilatorsantibiotics· Subjective Data· Cough unproductive· Outcome Criteria:Respiratory rate 12-16 breaths/min on 6/8/20No dyspneaNo circumoral cyanosisNo accessory muscles used to breatheCough effective, unproductiveClear breath soundsOral Temp 98.6F on 6/8/20 @ 8 AM Health Science Science Nursing NURSING NR160115 Share QuestionEmailCopy link Comments (0)