Tom Anderson is an 86-year-old white male who lives with his 82-year-old wife of 64 years in their home in upstate New York. Over the past few years, Mrs. Anderson has noticed a decline in her husband's mental status. Early on a January morning, Mrs. Anderson was at 4 am by the doorbell. When she opened the door, a neighbor was standing with her husband who was wearing nothing but his pajamas. The neighbor explained he saw Tom wandering outside on the snowy street. Tom was shivering uncontrollably and confused; the outdoor temperature was only 19° F. Mrs. Anderson immediately called 911 and had her husband transported to the hospital.
1. Upon arrival to the emergency department (ED), Mr. Anderson was assessed by the ED nurse, who noted the following assessment findings: (describe findings you would see)
2. What would the nurses' initial response be?
3. The findings were immediately reported to the physician; the nurse initiated the following orders of the physician: (what orders would you expect)
After several hours in the ED, Tom's core body temperature slowly rises to 35.4° C; he has stabilized but remains confused. He is admitted to the medical unit for further evaluation.
4. What further interventions might the nurse initiate?
5. What potential nursing diagnosis might apply? )
Pick one actual diagnosis and develop it through to the outcome stage.
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