Mrs. Baidoo 74year old female with history of COPD, Hypertension; Myocardial infarction, DM 2, was admitted to the medical unit of the hospital 3 days ago with pneumonia and heart failure. Upon admission, the client was having difficulty breathing and had an elevated temperature and white blood cell count. Claforan Iv was ordered to treat the pneumonia. Her weight had increased by 6 pounds in th e5 days preceding admission and she had significant swelling in her lower extremities. Mrs. Baidoo was receiving IV furosemide(Lasix) twice a day. She became very short of breath while ambulating to the bathroom. To promote rest, an indwelling urinary catheter was inserted. During the last 24 hours her condition deteriorated and she was transferred to the ICU.
Mrs. Baidoo was admitted to the ICU seven hours ago with Septic shock. Her last set of vital signs were BP 82/66, Pulse 120, labored respirations of 32 per minute, Temp 101.2 F (38.4 C) and her oxygen saturation is 90% on 6 L. Mrs. Baidoo’s skin is pale and moist, her radial pulse is rapid and thready, capillary refill is 3 seconds and she is complaining of nausea. The nurse auscultates crackles and wheezes in all lung fields and her bowel sounds are hypoactive. Mrs. Baidoo is restless and has difficulty answering questions at times because of slight confusion. The physician has ordered her urine output to be measured every hour; her last hourly output is 18 ml.
Subjective, Objective, 3goal, one nursing diagnosis , three nursing interventions with a rationale for each, and 3 expected outcome for each goal.
THREE GOALS; ONE GOAL, SHOULD HAVE THREE NURSING INTERVENTION each.
APA FORMAT THREE REFERENCES