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Lecture notes

Nursing and healthcare

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Nursing Interventions and Rationale 1. Provide supplemental oxygen, if need be, that is when SpO2 levels are below the normal limits. Rationale: To help maintain the oxygen saturation of blood in the arteries in normal ranges, that is 90% and above. 2. Administer medications as prescribed. Rati...

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  • April 24, 2023
  • 3
  • 2022/2023
  • Lecture notes
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NURSING PROCESS AND CRITICAL THINKING
BIOGRAPHICAL DATA
Age: 91 years old
Sex: Female
Weight: 56.8kg
Allergies: Penicillin, Sulphur and Antibiotic
Primary Diagnosis: Dementia, Coronary heart disease.
In your own words identify the holistic patient problems that are within the realm of the
nursing role i.e. a response to disease, illness or client situation
1. Chest pains when there is decreased blood supply to the heart muscles due to blocked arteries.
2. Shortness of breath
3. Fatigue
4. Cyanosis or bluing of the extremities due to decreased tissue perfusion caused by inability of
the heart to pump enough oxygenated blood to all parts of the body.


Choose one of the patient problems and cluster assessment data:(List the assessment data
that supports your patient)
Chest pain
Objective data
Facial expression showing pain
High pulse rate and blood pressure.
Abnormal heart sounds (murmurs) on auscultation.
Irregular heartbeats.
Difficulty breathing with the resident noticed to hold her chest.
Subjective data
The resident complains of chest pain.
The resident reports difficulty and rapid breathing while sitting or lying.
The resident reports loud and fast heartbeats
The resident reports shortness of breath both at rest and during physical activity.

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