Question - The RN is developing a plan of care for a 78-year-old patient who was admitted from home with a medical diagnosis of pneumonia and dehydration. Medical orders read: out of bed 3 times a day, oxygen 2 liters nasal cannula, and regular diet as tolerated. The patient's vital signs are temperature 100.8° F, heart rate 88 respiratory rate 18, B/P 100/68, pulse oximetry 91%. The patient has tenting at the clavicle. The patient has a productive cough with green-yellow sputum and is short of breath with all activities. An intravenous infusion of normal saline is infusing at 100 mL per hour. The chest x ray shows consolidation in the bases. The RN has included the following NANDA-I nursing diagnoses in the plan of care:
Ineffective airway clearance
Activity intolerance
Deficient fluid volume
Initial Discussion Post:
Identify what relevant data you will cluster to support one (1) of the identified NANDA-I nursing diagnoses?
Prepare three (3)-part nursing diagnostic statement for the nursing diagnosis you have chosen.
Discuss a measurable outcome with a time-frame for this patient.
Provide a rationale for the nursing diagnosis you chose.