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Arthur Thomason 56-year-old MVA victim, fourth day post op with a splenectomy and
femur repair. He is experiencing new onset of shortness of breath and has a nasal
cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily
orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP
now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored,
heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His
coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2
(hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is
obviously worsened from the shift before in overall condition. - ✔✔Alteration in
comfort: True
Alteration in gas exchange: True
Ineffectual airway clearance: True
Potential for shock: True
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,Prolonged confusion: True
Anxiety/fear: True
Potential for failure to thrive: True
Charlie Raymond 65-year-old male who was admitted to a negative pressure room on
Med-Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes
type II, and a recent myocardial infarction. He is a retired postal worker who lives at
home with his wife. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin.
Initially this cardiologist was concerned about congestive heart failure and Mr.
Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema.
Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature
100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to
COVID-19 Pandemic. - ✔✔Acute discomfort False
Alteration in body image False
Alteration in gas exchange True
Alteration in physical mobility True
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,Alteration in skin integrity False
.Bleeding False
Death anxiety True
Esteem False
.Ineffectual breathing pattern True
Knowledge deficit True
Sudden confusion False
Donald Lyles 52-year old male, was admitted yesterday evening for stabilization of his
uncontrolled type II diabetes. He is married, and his wife is requesting to stay at his
side. His HbgA1c is 10.6%. He has a history of a Myocardial Infarction, MI, one year
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, ago, and has refused all cardiac rehab, and has not had another cardiac event. He
refuses to comply with dietary recommendations. His BMI is 37. Vital signs are: BP:
146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl -
✔✔Select appropriate nursing concerns below based upon patient report above:
Acute discomfort False
Alteration in comfort False
Knowledge Deficit True
Nausea False
Potential for falls False
Potential for infection True
Estelle Hatcher
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