One (1) complete actual nursing diagnoses,

I. One (1) complete actual nursing diagnoses,

II. One (1) complete risk/potential

III. Five nursing intervention per diagnosis (two interventions should involve teaching)

IV. One short term goal

V. Objective and Subjective data

VI. Evaluation for the care

You are a nurse admitting a patient to the hospital from the emergency

department (ED) with shortness of breath and recent weight loss. After receiving

a report from the ED nurse, you ready the patient’s room according to unit

specifications and collect the necessary equipment and forms. When the patient

arrives, she is using oxygen via a nasal cannula and seems to be comfortable.

As you begin your admission activities and paperwork, you note that her

shortness of breath slightly increases as she answers your questions.

Accompanying the patient is her daughter, who comments, “This is the fourth

time she’s been admitted to this hospital in the past year.” The patient and her

daughter demonstrate a close, loving relationship. The daughter not only

encourages her mother but also sets boundaries regarding her mother’s anxiety.