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Asked by MinisterTarsier1982

Sue is a nursing student. She is to care for Mr. Nelson, a 63-year-old client who was admitted to the hospital with congestive heart failure and pneumonia. He reports becoming fatigued easily during care activities and states, “I feel short of breath if I try to do too much.” Sue notes he has 3+ edema in his lower extremities. Sue has identified the nursing diagnoses of decreased cardiac output and activity intolerance.

Sue must still perform hygiene measures, change the client’s IV dressing, get him up into a chair and measure noontime vital signs.

a. Define the nursing diagnoses decreased cardiac output and activity intolerance.

b. Before Sue begins her interview, how can she make Mr. Nelson more comfortable?

c. What objective data does Sue obtain as part of her nursing assessment? What nursing actions may be implemented based on this information?

d. Because Sue thins that Mr. Nelson may be at risk for falling, she decides to get assistance from a colleague before trying to get him into a chair. This is an example of what type of implementation skill?

e. When changing Mr. Nelson’s IV dressing, Sue cleans the insertion site in accordance with clinical practice guidelines and checks the site for signs of phlebitis. These steps are example of what type of direct care measure?

*TIP: Making a concept map regarding the case can help you organize the data and recognize what actual/potential health challenges can arise from the disease/s*

 

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SCIENCE
HEALTH SCIENCE
NURSING
NRSG 953

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