The nurse is caring for Oliva Jamison 77 years old, and was admitted to the medical unit with
exacerbation of COPD. Vital signs upon admission to the unit is: Blood Pressure 156/88, Pulse 101;
Respiratory Rate 28, Temperature 97.8°F The client reports worsening shortness of breath, extreme
fatigue, decreased appetite, and a weight loss of 15 pounds over the past three months. The
nurse notices the client is lying flat in bed and currently on 2L O, via nasal canula with an oxygen
saturation level of 88%. Other
symptoms include a dry cough, inspiratory and expiratory wheezes
upon auscultation of breath sounds. Respiratory treatments (albuterol) are ordered every 4 hr as
needed. The client reports having little or no family support
Assessment Questions
1. Identify the relevant subjective and objective assessment information related to the client's
condition and place the findings in the assessment data box below. (Recognizing cues;
Assessment)
2. Based upon assessment information, identify and prioritize the top 3 client problems. Write one
client problem in each of the Client Problem boxes below. (Analyze Cues; Analysis and Prioritize
Hypothesis; Planning)
3. Below each client problem, determine and enter the relevant assessment information that
supports the identified client problem. (Analyze Cues; Analysis and Prioritize Hypothesis;
Planning)
4. Identify important nursing interventions that should be taken to address each client problem
and enter them in the related intervention box for the associated client problem. (Take Action;
Implementation)