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Ineffective airway clearance

Bilateral fine and course


crackles
Incentive spirometer
White, frothy sputum
HOB elevated 45 degrees
Pleural effusions

Infection
Elevated bands: 59%
Temp: 98.
Droplet precautions
Abx: levofloxacin
Lymphocytes: 6
Long-term immunosuppressant
use (for kidney transplant done
in 2007

Decreased gas exchange/


oxygenation
O2 sat 94% on 0.5 L O2
NC; drops to low 80s
when ambulating
RR: 18
Hmg: 32.1%
Hgb: 10

Chief medical diagnoses:


Acute interstitial pneumonia
Cough
Fever

Activity intolerance/Immobility
Hypothyroidism - fatigue
Osteoporosis
Fall precautions
Long-term
Immunosuppressant use for
kidney transplant in 2007
O2 sat: low 80s when
ambulating
Uses walker at home

Priority Assessments:
lung sounds, sputum production, O2
sat, RR, pain, CBC's, temperature

Electrolyte imbalance
Na+: 131 (low)
Ca+: 6.9 (low)
Magnesium: 1.4 (low)
Anion gap: 3 (low)
Phosphorus: 2 (low)

Imbalanced nutrition: less than


body requirements
BMI: 20 (underweight)
Ensure TID with meals
Eats 25% of meals

Fluid overload
History of mitral valve repair
Hypertension
Edema on bilateral lower
extremities
Bilateral fine and course
crackles