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Shirley Smith Age: 52 Race: Caucasian Gender: Female Height: 68 inches Weight: 153 lb. (69.4 kg) Occupation: Retired Marital Status: Widowed Religion: Agnostic Allergies: None known Address: Assisted Living facility Immunizations: Up to date History Shirley’s husband died unexpectedly 2 months ago, which is the time she entered an assisted living facility. Shirley states she has become depressed from the loss of her husband and the inability to physically do activities she desires due to the COPD. Shirley presents to the ER with difficulty breathing and shortness of breath at rest, and increased fatigue. The patient is currently on 2 Liters of oxygen nasal canula at all times. Shirley smoked cigarettes for 32 years and just recently quit 2 months ago when she was put on full-time oxygen. Past medical history: hysterectomy at the age of 48, Gastroesophageal reflux disease (GERD), and Atrial Fibrillation. Medications Prednisone (HOLD) 20 mg oral Daily Pantoprazole 40 mg oral Daily Warfarin 5 mg oral Daily Methylprednisolone 125 mg IVP Every 6 hours Orders Maintain 2 liters of oxygen via nasal canula at all times to keep saturation =>92% • Hold prednisone • Methylprednisolone 125 mg IVP every 6 hours • Continue home medications: • Pantoprazole 40 mg oral daily • Warfarin 5 mg oral daily • Continuous pulse oximetry Notes Once admitted to the Med/Surg floor, Vital signs are obtained by the nursing assistant. • Temperature of 99.9 F • Pulse 102 • Respirations 32 • B/P 165/87 • Oxygen saturation 84% on 2 liters of oxygen via nasal canula The patient states she is short of breath, especially with activity. The alarm on the continuous pulse oximetry went off and created a loud pulsing chirp. What is a good nursing care plan for this patient , include the rationales for your priority patient selection, assessments, the nursing diagnosis, related factor, outcomes, and nursing interventions.

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