From the data provided, formulate a nursing diagnosis and a nursing care plan (by using A-ssessment, D-iagnosis, P-lanning/Goal, I-ntervention with Rationale, E-valuation) to be implemented in the emergency room for this client.

Intro To Health Care
4th Edition
ISBN:9781337338295
Author:Mitchell
Publisher:Mitchell
Chapter5: Medical Math
Section: Chapter Questions
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From the data provided, formulate a nursing diagnosis and a nursing care plan (by using A-ssessment, D-iagnosis, P-lanning/Goal, I-ntervention with Rationale, E-valuation) to be implemented in the emergency room for this client.

This is a case of a 65 year old female with a 10 year history of hypertension and diabetes. She
is taking Micardis 40 mg in the morning and Amlodipine 5 mg at night for hypertension. For
diabetes she is being given Janumet 100mg/1g 2x a day and Gliclazide 60 mg OD before
breakfast. The daughter reported poor compliance with medications.
The patient was brought to the emergency room due to difficult of breathing. Condition started
2 days PTA when the patient had easy fatigability going to the comfort room. She started
taking all her medications again but she did not seek consult. Symptom persisted until she
would have difficulty of breathing when getting out of bed.
In the emergency room BP 180/100 HR 110/min RR 35/min 02 sat 93%, Temp 36.8, patient is
pale, diaphoretic and in severe respiratory distress. (+) edema up to the knees area, (+)
crackles from lower to mid portion of the lungs.
In the emergency room, the client was given 02 per canula at 4-5lpm. IVF was initiated. The
doctor ordered for Furosemide 40 mg IV stat. CXR was done in the emergency room showing
pulmonary edema and heart enlargement
Transcribed Image Text:This is a case of a 65 year old female with a 10 year history of hypertension and diabetes. She is taking Micardis 40 mg in the morning and Amlodipine 5 mg at night for hypertension. For diabetes she is being given Janumet 100mg/1g 2x a day and Gliclazide 60 mg OD before breakfast. The daughter reported poor compliance with medications. The patient was brought to the emergency room due to difficult of breathing. Condition started 2 days PTA when the patient had easy fatigability going to the comfort room. She started taking all her medications again but she did not seek consult. Symptom persisted until she would have difficulty of breathing when getting out of bed. In the emergency room BP 180/100 HR 110/min RR 35/min 02 sat 93%, Temp 36.8, patient is pale, diaphoretic and in severe respiratory distress. (+) edema up to the knees area, (+) crackles from lower to mid portion of the lungs. In the emergency room, the client was given 02 per canula at 4-5lpm. IVF was initiated. The doctor ordered for Furosemide 40 mg IV stat. CXR was done in the emergency room showing pulmonary edema and heart enlargement
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