Nursing Assessment: Respiratory issues, patient care and diagnosis

This report presents a nursing assessment of a 38-year-old male patient, Frankley John, diagnosed with a cancerous tumor in the left lower lobe of the lung. The assessment includes subjective data such as the patient's distress, difficulty breathing, and desire to lose weight, as well as objective data including vital signs like blood pressure, pulse, and respiratory rate. The report details findings across various body systems, including respiratory, cardiovascular, and musculoskeletal, and identifies data clusters related to breathing difficulties, emotional distress, and lifestyle habits. A priority nursing diagnosis of acute breathing problem related to the cancerous tumor is established, along with goals to improve airway clearance, breathing comfort, and physical activity. The report suggests interventions such as respiratory medication, oxygen administration, and patient support to address the identified issues.

CONCEPT MAP PART 2
Name of the student:
Name of the Univesity:

ASSESSMENT:
Subjective:
Patient is distraught and crying
She feels like choking due to
breathing difficulty
He is worried
He wants to lose weight but
loved eating
Objective:
BP 120/65, Pulse 72, R 16
Weight 225 lbs
Temperature 99.8
BODY SYSTEMS:
Respiratory: Resp16 with a
persistent cough. While going
to the bathroom, R16. Frankley
John at times feel she is
choking.
Cardiovascular: P72, shortness
of breath
Integument: No integuments
Gastrointestinal: No data
Genitourinary: No data
Neurological: No pain score
Muscoskeletal: Needs
assistance while going to the
bathroom, difficult in
ambulating due to falls.
HEENT: No data
Neuro/sensory/mental status:
Mood changes observed as
Frankley states that he leaves
alone. He shouts at the nurse
too.
Emotional/social/spiritual: He
wants to loose weight, however
she loves eating. He gets angry
on the nurse and ask to leave
Reproductive: no data available
Gordon Pattern:
Cognitive
perception
Data Clusters:
•Shortness of
breath
•He feels like
choking due to
breathing
difficulty
•He is unable to
bring up her
secretions
Gordon Pattern:
Coping/stress
tolerance
Data Clusters:
•Wants to lose
weight, but loves
eating.
•Frankley is
worried that he
leaves alone and
he also shouts on
the nurse.
•He is very
distraught and
crying
Gordon Pattern:
Health
perception
Data Clusters:
He has the
intention to lose
weight, but no
intention to
control her
eating habits
smoking is a
weakness
•‘I don’t plan on
quitting’, ‘Eating
an entire pizza
with coke
Gordon Pattern:
Nutrition
metabolic
Data Clusters:
•He smokes 2
packs of
cigarettes.
•He is obese but
he does not
control her eating
habits.
•He was found to
have eat an entire
pizza pie and coke
with his wife
during hospital
stay
Gordon Pattern:
Activity/Exercise
•Data Clusters:
Need ambulatory
support while going
to the bathroom.
•He states ‘Its hard
for me to get
around, I use sticks
while walking
Priority Nursing diagnosis:
Acute breathing problem related
to cancerous tumor in the left lobe
evidenced by shortness of breath,
he feels like choking due to
breathing difficulty, he is unable to
bring up her secretions
Goal:
•To have a clear and effective airway and
respiratory pattern
•To reduce mucus secretion and breathing difficult
•To promote comfort and ease of breathing
•To improve patients ability to take part in physical
activities.
Patient:
Name: Frankley John
Age: 38 year old
Situation: Diagnosed with
cancerous tumoiur on the
left lower lobe of the lung
Cognitive
perception
Coping Health
perception Nutrition
metabolic Activity/exercise
•Assessment of respiratory rate and
ABG level to detect signs of respiratory
compromise
•Assessment of breathing patterns
•Providing respiratory medication and
oxygen to relax airway smooth
muscles
•Use suction secretion to clear airway
blockage
•Maintain proper body alignment and
support patient to do deep breaths to
promote deep inspiration