a low b/p by itself i would diagnose as decreased cardiac output r/t decreased contractility aeb low b/p of 77/49.
however, your instructor has a valid argument. a diagnosis is made on the basis of evidence that was collected and we determine its status by what happens to that evidence as time goes on. does it improve or stay the same? your goal statements are merely written predictions of how you think things will improve. and, yes, they must be measurable. a blood pressure is measured with a blood pressure cuff
. so, when you say things like "low blood pressure" and "the patient will have a normal blood pressure by noon" this cannot be measured. there are no "normal" markings on a blood pressure cuff. but if you say, "the patients blood pressure will return to 110/60 by noon," that
is measurable because we can put the blood pressure cuff on the patient and take a measurement and compare it against a parameter that we set.
decreased cardiac output r/t decreased contractility aeb low b/p of 77/49
the patient's blood pressure will return to 110/60 while on bed rest in 24 hours
by discharge the patient will demonstrate standing slowly when getting out of the bed or a chair.
impaired gas exchange r/t smoking as evidenced by copd
- ask the patient if he has experienced any weakness, nausea, dizziness and/or chest pain recently
- assess the skin for pallor, sweating and clamminess
- take lying, sitting and standing blood pressures q4h while awake and record
- palpate the pulses in the extremities of the arms and legs q4h while awake and record
- make sure the patient has his o2 tubing positioned correctly and that the o2 is on and running
- assist the patient when standing and ambulating and do not leave unattended
- encourage oral fluid intake
- if b/p goes below 80/60 or patient complains of dizziness maintain bed rest
- teach patient to stand slowly when getting out of the bed or a chair
- discuss the need for assistive devices for ambulation
- talk with the patient about the importance of adequate fluid intake
nausea r/t ?? (i don't know why he is nauseous??) aeb patient report of strong nauseous feeling (8/10)
the related factor and aeb are all wrong. there are only 2 related factors for impaired gas exchange.
- the alveoli are so damaged by disease that the o2/co2 interchange is compromised (alveolar-capillary membrane changes)
- the alveoli are so clogged up with exudates and secretions that the o2/co2 interchange is compromised (ventilation perfusion imbalance)
since this patient has copd the winner is alveolar-capillary membrane changes. smoking caused the problem. he has a more specific disease as well. copd is a broad term and there are 4 respiratory diseases that fall under it. emphysema or obstructive bronchitis are more likely what he has. your "as evidenced by
" part of the diagnostic statement is the data (evidence) you found that proves he has impaired gas exchange (excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane).
there is no way you assessed this patient and found him to have copd. only a doctor can do that. if you look at the defining characteristics (a fancy name for signs and symptoms) on this website you will see what some of the evidence of impaired gas exchange
is: impaired gas exchange
. your diagnostic statement should begin as impaired gas exchange r/t alveolar-capillary membrane changes aeb [the patient's symptoms]
not why he is nauseous, but what the underlying reason is for the nausea to have occurred. this is not uncommon with copders. it may be his medications. if he is having low b/ps he may also be having dizziness and dizziness leads to nausea. this hypotension he is having may be positional or it may be brought on by his coughing. the heart and lungs are so closely linked to each other that it is hard to know if they are not entwined here. nausea and heart problems often go hand in hand.