SCENARIO: Xandra Dela Cruz, a 29-year-old married teacher, was admittedto the hospital with an elevated temperature, a productive cough, and rapid, labored respirations. In taking a nursing history, Nurse Niana Provido, RN, finds that Xandra has had a “chest cold” for two weeks based on the interview, and has been experiencing shortness of breath upon exertion. Yesterday she developed an elevated temperature and began to experience “pain” in her “lungs.”Nurse Niana’s physical assessment reveals that vital signs are: Temperature, 39.4°C (103°F); pulse, 92 bpm; respirations, 28 cpm; and blood pressure, 122/80 mmHg. Nurse Niana observes that Xandra’s skin is dry, her cheeks are flushed, and she is experiencing chills. Auscultation reveals inspiratory crackles with diminished breath sounds in the right lung.After analysis, Nurse Niana formulates a nursing diagnosis and outcome statement.Guide in the creation of your NCP: – identify the subjective and objective data based on the scenario given. -What is the priority need of the client based on Maslow’s Hierarchy of need? – Formulate a nursing diagnosis. -What will be your background information based on your nursing diagnosis? -Formulate an outcome identification statement with 3 specific objectives based on your assessment and nursing diagnosis. -List down your interventions and rationale based on your assessment, diagnosis and outcome identification statement. -Finally, you will evaluate the patient’s progress toward attainment of outcomes. Health Science Science Nursing NR 225 Share QuestionEmailCopy link Comments (0)
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