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NUR 302 Nursing

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Question:

The RN is developing a plan of care for a 78 year old patient who was admitted from home with a medical diagnoses of pneumonia and dehydration.The medical order reads: Out of bed 3 times a day, oyygen 2LPM per nasal canula and regular diet as tolerated.The patient's vital signs are T100.8, HR88 RR18 BP100/68 Sat 91%.
 
Tinting at the clavicle.The patient has productive cough with green - yellow sputum and is short of breath with all activity.An intravenius infusion of Normal saline is infusing at 100ml per hours.The chest X rays show consilidation in the base.
 
The Rn has included the following nanda, nursing diagnoses in the plan of care .1)ineffective air way clearance(2) Activity intolerance(3) Deficient..
 
Identify what relevant data you will cluster to support one of the identified Nursing diagnoses you chose(3) Writer a three part nursing diagnoses statement for the nursing diagnoses you have chosen (4)Write a measurable out come with a time frame for this patient , provide a rationale for the nursing diagnoses you chose.
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