(Solved): CASE SCENARIO NURSING PROCESS: ASSESSMENT \& DIAGNOSIS A 17-year old female brought to the Emergenc ...

CASE SCENARIO NURSING PROCESS: ASSESSMENT \& DIAGNOSIS A 17-year old female brought to the Emergency Department with complaints of severe shortness of breath and anxiety. The patient has a past medical history of asthma. She reports that she was playing soccer with friends when the symptoms started. She used her rescue inhaler but symptoms persisted and started to worsen. After 30 minutes of severe shortness of breath, her mother drove her to the hospital. Upon assessment, the patient is diaphoretic and visibly uncomfortable. She cannot complete a full sentence without gasping, and asks "Am I... going to... die?" She is hunched over, her breathing is labored, and retractions are seen. Upon auscultation, both inspiratory and expiratory wheezes are heard. Her temperature is $$37.6\mathrm{C}$$, heart rate is 113 beats per minute, blood pressure $$115/78\mathrm{mmHg}$$, respirations are 35 breaths per minute, and oxygen saturation is $$89\%$$ on non-rebreathers. An ABG is drawn, revealing $$\mathrm{pH}7.49,\mathrm{PaCO}2$$ is $$29\mathrm{mmHg},\mathrm{PaO}2$$ is 52 $$\mathrm{mmHg}$$, and $$\mathrm{HCO}3$$ is $$22\mathrm{meq}/\mathrm{L}$$, revealing respiratory alkalosis. A peak flow measurement is performed and the patient's zone is "red" indicating severe narrowing of the large airways. The patient is admitted to the hospital for Acute Exacerbation of Bronchial Asthma. Guide Question 1. Follow the steps in formulating the nursing process ( 5 phases) 2. Identify the subjective and objective cue based on the case scenario given above? 3. Formulate nursing care plan using the NANDA \& NANDA TAXONOMY II