Key Problem #1
Ineffective Airway Clearance
Supporting Data:
- Dx of Pneumonia
- Hx of COPD
- Hx of Smoking 1 PPD
- Hx of Lung Cancer
- Hx of Obesity
- Hx of Hypoxemia
- Hx of Generalized Anxiety
Disorder
- Hx of Fatigue r/t lack of oxygen
- X-Ray: Left pleural effusion with
atelectasis
- Productive cough, thin/tan sputum
secretions
-Diminished breath sounds
bilaterally d/t lack of tissue
perfusion & secretions
- Dyspnea AEB uncomfortable
breathing and SOB
- A & O x 2: disoriented to place
and situation r/t decreased oxygen
- Increased respirations @23 d/t
lack of oxygen
- DuoNeb PRN q4h
- Ativan 2 mg oral q8h
Key Problem # 4
Impaired Cardiac Tissue
Perfusion
Supporting Data:
- Dx of Pneumonia
- Hx of COPD
- Dyspnea AEB uncomfortable
breathing and SOB
- Abnormal ABGs: pH: 7.461.
PCO2: 37.1. PO2: 80.8. HCO3:
25.9. (Uncompensated Metabolic
Alkalosis)
- Nasal flaring d/t lack of oxygen
r/t impaired tissue perfusion
- Pallor
- Decreased Post Tibial pulse +1
bilateral
- Decreased Pedal pulse +1
bilateral
- Bilateral edema in hands +1
- Excessive sweating
- Cool/Moist skin
- Cold upper and lower
extremities bilateral
Key Problem #6
Impaired Physical Mobility
Supporting Data:
- Dx of Pneumonia
- Hx of COPD
- Hx of Obesity
- Hx of Coronary Artery Disease
- Hx of Peripheral Artery Disease
- Bilateral weakness of upper and
lower extremities
- Bilateral limited movement (50-
75%) of upper and lower
extremities
- Hx of Chest Pain
- Hx of Abdominal Pain
- Hx of Acute and Chronic back
pain
- A & O x 2: disoriented to place
and situation r/t decreased oxygen
- Sedentary Lifestyle
- Hx of Lumbar Degenerative
Joint Disease
- Hx of Depression
Key Problem #2 Key Problem# 3
Impaired Gas Exchange Decreased Cardiac Output
1
Supporting Data:
Supporting Data:
- Dx of Pneumonia
- Dx of Pneumonia
- Hx of COPD
- Hx of COPD
- Hx of Smoking 1 PPD
- Hx of Smoking 1 PPD
- Hx of Lung Cancer
- Hx of Lung Cancer
- Hx of Obesity
- Hx of Obesity
- Hx of Depression r/t decreased
- Hx of Coronary Artery Disease
oxygen
- Hx of Peripheral Artery Disease
- Hx of Generalized Anxiety
- Hx of Hypertension
Disorder
- Hx of Hypercholesterolemia
- Hx of Fatigue r/t lack of oxygen
- Hx of Hyperlipidemia r/t high
- A & O x 2: disoriented to place
levels of lipids in the blood
and situation r/t decreased oxygen
- Hx of Syncope (fainting)
- Increased respirations @ 23 d/t
- Hx of General Anxiety Disorder
lack of oxygen
- Pallor
- Pallor r/t decreased blood flow
- Cold upper and lower
- Dyspnea AEB uncomfortable
extremities bilateral
breathing and SOB
- A & O x 2: disoriented to place
- Nasal flaring r/t decreased
and situation r/t decreased oxygen
oxygen
- Decreased Post Tibial pulse +1
-Irritability/Restlessness r/t
bilateral
decreased oxygen
- Decreased Pedal pulse +1
- X-Ray: Left pleural effusion with
bilateral
atelectasis
- Bilateral edema in hands +1
- DuoNeb PRN q4h
- Aspirin 81 mg oral daily
- Ativan 2 mg oral q8h
- Lipitor 80 mg oral daily
Reason for Needing Health Care Key Problem#5
Deficient Fluid Volume
Medical Diagnosis:
- Acute Respiratory Distress Syndrome (ARDS) with Supporting Data:
Pneumonia -Tenting skin turgor
- 62 year old male, Full Code - Dry Mucous Membranes
- Elevated BUN - 41 (8-23) with
Key Assessment: decreased Creatinine - 0.6 (0.7-
-VS, Lab Values, Breath sounds, secretions, 1.2)
respiratory patterns, ABGs, Chest X-Ray, Behavior & - Bilateral edema in hands +1
mental status, Skin, and I&O. - Excessive thirst
- Fluid Imbalance. I&O -3646 on
Allergies: 10/26. 228.8 on my shift on
Avelox, Biaxin, Ciprofloxacin, Levofloxacin, 10/27
Percocet, Vicodin, Sulfa Antibiotics - Decreased Post Tibial pulse +1
bilateral
- Decreased Pedal pulse +1
bilateral
- Excessive Sweating
- Dextrose 5% and Sodium
Chloride 0.9%
Key problem # 7 *Psychosocial*
Altered Mental Status
Supporting Data: I dont know where this fits with
- Hx of Bipolar Disorder the problems.
- Hx of COPD r/t decreased oxygen
- Hx of Coronary Artery Disease r/t - Patient was extubated to 5
decreased oxygen liters/minute via Nasal Canula on
- Hx of Peripheral Artery Disease 10/26. On 10/27 patient was on 3
- Infection d/t Pneumonia liters/minute.
- A & O x 2: disoriented to place and
situation r/t decreased oxygen - Increased lab values of Platelets,
- Hx of Hypoxemia WBC, and Neutrophils r/t
- Hx of Syncope Pneumonia.
- Dyspnea AEB uncomfortable
breathing and SOB
- Seroquel 75mg Oral 2x daily
(bipolar disorder)
- Precedex5.2 mL/HR IV continuous.
(Sedation)