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Data (patient data including subjective & objective): Action (nursing intervention): Response (of the client; data compared to pre-interventional data): I keep having to redo this and need help. Please . What are two problem-based nursing diagnoses according the NANDA-I for a patient with acute pericarditis? Of the 2 diagnoses determined above, determine the higher-priority diagnosis in 3-part format with related-to and as-evidenced-by factors. For the High Priority Nursing Diagnosis, develop 2 expected outcomes for the client. For each outcome, develop 2 related nursing interventions; interventions should be appropriate for and individualized to the client. For each intervention, include rationale (why the intervention is appropriate and individualized) and an in-text citation supporting that it is evidence-based. Outcomes should be specific and address only 1 parameter. Outcomes should be measureable and relate to an observable change. Outcomes should be achievable and agreed-upon with the client. Outcomes should be realistic based on the client’s abilities, preferences and resources. Outcomes should be time-limited (generally within the shift so the nurse can evaluate). Patient information: presented to the ED with multiple complaints of pain and generalized malaise. Since Monday he has had multiple problems including chest pain, shortness of breath. His abdomen and back have an achey pain (10/10), though he says if his sugar is under control its better but he can’t stand up. L side chest pain started Monday too, sharp in nature, deep breath make it worse. No recent trauma. Last BM daily. Headache frontal times 3 days. Chronic blurry vision from cataracts. He is lightheaded on standing up but otherwise no dizziness. No nausea, vomiting, dysuria, cough, pain with chewing or coughing. Walks with a cane. No heart attacks or stents. Takes meds as prescribed. Has urinary frequency sometimes with urgency. Has history of diabetes, hypertension, cataracts, and anemia. Age: 60s Gender: Male Marital Status: Single Occupation: retired. School bus driver Support system: Children and family members. Reason for for seeking care from patient’s own words: “Pain all over” Admitting Medical Diagnosis: Acute Pericarditis Allergies and reactions: Metformin, anxiety Vital Signs: BP is 168/86 on left arm while patient was sitting. Pulse is 75 bpm, Respirations is 18bpm, Height is 5’9″, Weight is 306 pounds, SPO2 94% ; BMI is 45.19 kg/m^2 Cardiovascular: regular rhythm, tachycardia present, no murmurs heard during heart sounds, no friction rub, no gallop Peripheral Vascular: warm/ well-perfused, no edema, no joint warmth or erythema. Respiratory: thorax was symmetric and equal in rage during chest expansion. Lungs are clear bilaterally. No adventitious sounds. Pain: patient with acute onset left sided sharp chest pain with diffuse ST elevations. No stemi, troponin negative. Pain worsens w/deep inspiration and sharp all more consistent with pericarditis than ischemia. Abdominal: Bowel sounds are normal. Abdomen is soft and there is no mass during palpations. Abdominal tenderness (mild discomfort to palpation diffusely). There is no guarding. Skin: is dry and warm, normal turgor. Findings: rash (macular, erythematous rash to the LLQ of the abdomen with in punctuate skin break at right border. No tenderness, purulence, or fluctuance present. Neuro: no acute motor or sensory deficits, alert and oriented to person , place, time, CNII-XII grossly intact. Transxemic attack- occlusion caused symptoms GU: positive for difficulty urinating. Negative for dysuria. Abdomen/GI: positive for abdominal pain and constipation, negative for nauseas and vomiting. Lines: Left peripheral IV on AC 2g Lab values during admission: WBC 10.3, HGB: 9.5, Platelet 115, Sodium 138, Potassium 3.6, Chloride 104, CO2 26, BUN 33, Creatinine 1.39, Calcium 8.8, Glucose 209, Hematocrit 31.1 Electrocardiogram during admission: reveals abnormal sinus rhythm rate 101 with diffuse ST elevations in all leads. No ST depressions or t-wave inversions. Lab values day after admission: WBC 10.4, HGB 9.3, Platelet 115, Sodium, 136, Potassium 3.6, Chloride 104, CO2 24, BUN 33, Creatinine 1.35, Calcium 8.6, Glucose 224, Hematocrit 30.1 Radiology during admission: XR Chest 1 VW. Findings: There is no evidence for consolidative infiltrate, pneumothorax, or pleural effusion. Cardiomegaly is demonstrated with a stable residual prominence of the central pulmonary vasculature. No acute abnormalities are seen. Impressions: no acute cardiopulmonary process demonstrated. Transthoracic Echo (TTE) day after admission: Findings were normal Family history: sister- diabetes mellitus, mother- diabetes mellitus and hypertension, father-diabetes mellitus and hypertension (deceased), maternal grandparents – diabete mellitus and hypertension (deceased) Social history: no tobacco, no alcohol, no recreational drugs. Surgical history: 12/2015 completed a colonoscopy with biopsy as a well as erosive gastritis Medications: albuterol 2.5 mg, inhalation, TID allopurinol, 100 mg, oral, BID aspirin delayed release, 81 mg, oral, daily with breakfast Atorvastatin, 20 mg, oral, bedtime carvedilol, 3.125 mg, oral, BID with meals colchicine, 0.6 mg, oral, BID enoxaparin, 40 mg, subcutaneous, q12h SCH ferrous sulfate, 1 tablet, oral, Daily with breakfast hydrochlorothiazide, 12.5mg, oral daily Indomethacin, 50 mg, oral, TID with meals insulin regular, 3 units, subcutaneous, TID losartan, 100mg, oral, daily nifedipine XL, 30 mg, oral , daily polyethylene glycol, 17 g, oral, daily Outcome 1: The client will … Nursing Intervention 1: The nurse will … Rationale: Evidence-based: Nursing Intervention 2: The nurse will … Rationale: Evidence-based: Outcome 2: The client will … Nursing Intervention 1: The nurse will … Rationale: Evidence-based: Nursing Intervention 2: The nurse will … Rationale: Evidence-based:

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