JV, a 62-year old male is admitted to the general medical surgical…
Question Answered step-by-step JV, a 62-year old male is admitted to the general medical surgical… JV, a 62-year old male is admitted to the general medical surgical floor due to shortness of breath at rest, rule out pneumonia. Past Medical History (PMH): Diabetes Mellitus Type 2 (diagnosed 5 years ago), GERD, bilateral knee replacements due to osteoarthritis (2 and 3 years ago), appendectomy (10 years ago). Previous treatment for latent TB (3 years ago). Social History: Married, non-smoker, non-drinker, retired from military service Home Meds: Metformin 1000 mg 2 x/day, Mobic 7.5 mg daily, Lyrica 150 mg 3 x/day, Pepcid 20 mg daily. Vicodin 5/500 1-2 pills every 6 hours prn severe pain. Current Vital Signs taken by UAP: T: 102.2 F (oral), P: 88 and regular, R: 32 and shallow, Pulse Ox 88% on room air. Weight 232 pounds. Fingerstick blood sugar: 312 Current Orders:Labs: CBC, CMP, Blood cultures, sputum cultureChest CT scanIV: ½ normal saline at 100 mL/hourVancomycin 750 mg in 250 mL every 12 hours IV after cultures obtainedRespiratory therapy nebulizer treatments every 2 hours and prn shortness of breathPulmonary consultFingerstick blood sugars AC, HS, and 0200 with sliding scale insulinO2 2 lpm per nasal cannulaVital signs every 4 hoursContinuous pulse oximeter Patient complains of: productive cough, fever and chills for 3 days, increasing shortness of breath, unable to talk in full sentences. States “My wife insisted I come in”. States he is unable to walk to and from bathroom without getting “winded”.Refer to the attached Case Study for this assignment. This is part 1 of a multi-tiered assignment working through the nursing process of ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation). This assignment will concentrate on nursing assessments and nursing diagnoses and how they differ from medical diagnoses. Points to consider, based on the case study:What assessment might be anticipated being performed relevant to the case study?What are the priority assessments and rationales?What nursing diagnoses would be appropriate for the client in the case study? Provide rationales.Which would be the priority nursing diagnoses? Provide rationales. Health Science Science Nursing BIO 1123 Share QuestionEmailCopy link Comments (0)
