J.M. is a 71 year old man diagnosed with type II diabetes 10 years ago with an average blood sugar..

J.M. is a 71 year old man diagnosed with type II diabetes 10
years ago with an average blood sugar of 220 mg/dl. In addition, J.M. was
diagnosed with congestive heart failure 15 years after his 5 vessel coronary
artery bypass grafts (CABG). The cardiac history is a result of the untreated
hypertension he suffered from for 12 years before his bypass surgery. Physical
assessment data reveals: oral temperature 98.4 F, respiratory rate 10 bpm,
apical pulse 128 bpm, blood pressure 186/96 mm Hg, and pulse oximetry is 80%,
and crackles scattered throughout all lung fields. J.M. complains of
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J.M. is a 71 year old man diagnosed with type II diabetes 10
years ago with an average blood sugar of 220 mg/dl. In addition, J.M. was
diagnosed with congestive heart failure 15 years after his 5 vessel coronary
artery bypass grafts (CABG). The cardiac history is a result of the untreated
hypertension he suffered from for 12 years before his bypass surgery. Physical
assessment data reveals: oral temperature 98.4 F, respiratory rate 10 bpm,
apical pulse 128 bpm, blood pressure 186/96 mm Hg, and pulse oximetry is 80%,
and crackles scattered throughout all lung fields. J.M. complains of shortness
of breath (SOB) with activity, denies pain, is able to perform ADLs, states
problems with swallowing thin liquids, and requests to be placed in high
Flower’s position. Respiratory pattern is irregular and shallow. J.M. is alert
and oriented to person and place, and skin is cool, moist, and pale. Bowel
sounds are active in all 4 quadrants, and the abdomen is semi hard and slightly
distended. J.M. has (+2) pitting edema to the lower extremities

The following questions will guide your development of a
nursing care plan for the case study.

1. List subjective and objective assessment data.

2. What acid-base imbalance does the nurse suspect?

3. Select 3 priority nursing diagnoses for J.M.’s acid-base
imbalance.

4. Choose the priority nursing diagnosis and develop an
appropriate client centered goal.

5. What nursing interventions should the nurse implement to
assist J.M.?

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