1 Nursing care plan Assessment

Pages: 1 pages ( 275 words, Double spaced)

Sources: 1

Pages: 1 pages ( 275 words, Double spaced) Sources: 1 Nursing care plan Assessment (subjective and objective data) Nursing diagnosis (4 minimum with related factors) Goals (min of 6) Interventions (minimum of 6) Subjective assessment: COPD hypertension right head surgery about 7years ago Allergy to selfish Take COPD med, Swelling on his feet Smoke every day Shortness of breath when he walks too long Last time he ate was yesterday Urine is a little dark Bowel movement yesterday Patient Introduction Mr. Toua Xiong arrived in the clinic 1 hour ago, accompanied by his wife, with complaints of difficulty swallowing and pain in his throat and mouth. Dr. Sabin has not yet seen the patient. Mr. Xiong is a 64-year-old male. He has a history of COPD, diagnosed 5 years ago, and he has been to the unit before, for chronic management of his COPD. Mr. Xiong’s wife says her husband is complaining of difficulty swallowing and pain in his throat and mouth, and that it has bothered him when eating or drinking for the last 3 to 4 days. He brought both of his inhalers and his portable oxygen tank from home, and states that he has been taking his medication as prescribed. We have taken a blood sample for ABG, CBC, and BMP as ordered; the results are pending. At his arrival his vital signs were: BP: 104/62 mmHg, HR: 97/min, RR: 19/min, and SpO2 91%. No other assessments have been completed at this point. Mr. Xiong is waiting in exam room 2. Dr. Sabin will come to see the patient soon but asks that you take the patient history and complete the physical assessment now. Also, he said to monitor the SpO2 and titrate to keep it above 90%, but not to give more than 2 L of oxygen/min.

Problem Identification


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