Page 26 - Advanced Communication in Nursing

tachycardia, Hb
7.2g
Vital sign
BP: 90/50
P: 90
T: 37.2 C
R: 22

Case 2
Assessment Diagnosis Planning Interventions
Subjective: Ineffective airway After 3 days of
The Pt said, “I am clearance related nursing
having trouble to to increased interventions, the
breathe” production o patient will
secretions. demonstrate
Objective: behaviors to
Use of accessory improve airway
muscle clearance.
Abnormal breath
sounds
Vital Sign:
T: 37.3 C
P: 82
R: 25
BP: 110/80

Case 3
Assessment Diagnosis Planning Interventions
Subjective: Fluid volume After 8 hrs of
The Pt said, “I feel deficient related nursing
weak and I’m to osmotic diuresis interventions, the
always thirsty”. from patient will
hyperglycemia. demonstrate
Objective: adequate hydration.
dry skin and mucus
membrane
Poor skin turgor
Sudden weight loss
Vital sign
T: 37.1 C
P: 85
R: 20
BP: 110/80

pg. 18