Introduction
The nursing process is a blueprint for care. Critical thinking is the cognitive process the nurses use when developing and implementing the nursing process (Crisp & Taylor, 2005). The nursing process is an ongoing systematic series of actions, interactions, and transaction with a person(s) in need of health care, using problem solving methods so that empathic and intellectual processes and scientific knowledge form the basis for your outward actions observable to others.(Murray, Huelskoetter & O’ Driscoll, 1980). The nursing process has five steps, assessment, diagnosis, expected outcome, intervention and evaluation. Assessment is whereby subjective data and objective data is collected by interviewing of the patient. Nursing Diagnosis deals with making clinical judgments through the assessment made. Expected outcome is planning what is to be done on the patient to improve and maintain his/her condition. Intervention is putting planning into actions inorder for effective care to be given and Evaluation involves forming an opinion on of the health care provided or assessing if the expected outcome is achieved. Nonetheless, the nursing process is used as a common framework for making practice decisions in nursing about diagnosis and treatment of human responses to health and illness (Parker & Clare, 2000). Thus, this assignment will elaborate on the case scenario of 40 year old lady stating that she has productive cough for 3 weeks and other health relating issues due to cough. Hence a nursing care plan will be prepared for this patient inorder to provide an effective health care.
Assessment
Subjective Data
• Mrs. X who is 40 years of age states that the cough is productive for 3 weeks till
date.
• She also noticed that the content of her sputum is yellow in color and thick.
• Her cough started when she had mild fever 3 week ago and gets severe at night inhalation.
• She started to experience headache when she coughed for the past 3 days.
• Also experiences sharp pain and throbbing which worsens when she lies down.
• Mrs. X had had a similar episode of cough and headache a year ago and was treated.
• She has a family history of asthma and diabetes.
• Her daily living activities is also affected because she cannot move around to do her daily household chores as cooking
• She is assisted by her aunty for her elimination and personal hygiene daily.
Objective Data
• Chest movement
• Crackling sound
• Fatigue
• Looks pale
• Vital signs were taken as follows :
Temperature- 37.9 degree Celsius
Pressure – 92 beats/min
Respiratory- 22 per min
Blood Pressure- 130/80
Weight
Diagnosis
• Ineffective Breathing Pattern
• Impaired gas exchange
• Acute Pain
• Hyperthermia
• Disturbed Sleep pattern
• Toileting self-care deficit
• Impaired physical mobility
• Risk for infection
• Fatigue
• Imbalanced nutrition: more than body requirements
Interventions
• Observe the respiratory rate and the position that the patient is comfortable breathing. (independent)
• Check the lungs for areas of decreased ventilation and presence of adventitious sound.(independent)
• Check and observe the pain characteristics and assess for signs and symptoms of the pain such as the sharpness of the pain.(independent)
• Check the patient’s temperature to see if there are any changes or not. (independent).Provide fluid and tepid bath to cool. (collaborative)
• Monitor the clients sleeping pattern and her usual bedtime routines. (independent) . Keep environment quiet as possible and advise her on taking hot or warm fluids before bed to ease her when sleeping.(collaborative)
• Assess the ability to perform self-care including bathing cleaning up and dressing. Provide a way to do a shower, cleanup and getting dressed, family can train and support the client ability to self-care. (collaborative)
• Check for bed mobility, unsupported or supported sitting and other transition movements such as sit to stand & walking activities. Consult a physical therapist for further checkup. (collaborative)
• Observe the color of the respiratory secretions.
• Assess frequency of fatigue, activities associated with increased fatigue, ability to perform activities of daily living (ADLs), times of increased energy, ability to concentrate, and usual pattern of activity.(Nanda Nursing Diagnosis, 2011)
• Determine healthy body weight for age and height. Refer to dietitian for complete nutrition assessment. Assess client’s ability to obtain and use essential nutrients.
Diagnosis Expected Outcome Intervention Evaluation
Ineffective breathing pattern To maintain an effective breathing pattern within a week. (short term goal) Observe the respiratory rate and the position that the patient is comfortable breathing. (independent) A normal respiratory rate was obtained by the end of the week
Impaired gas exchange To maintain optimal gas exchange within 1 week. (Gulanick &Myers, 2011) (short term goal) Check the lungs for areas of decreased ventilation and presence of adventitious sound.(independent) The patient was able to obtain an optimal gas exchange .The lungs were checked and sounds were observed and is normal
Acute Pain After 4 hours days the patient should report with minimal pain at a level less than 3 to 4 on a
rating scale of 0 to 10. (Gulanick &Myers, 2011).
Check and observe the pain characteristics and assess for signs and symptoms of the pain such as the
sharpness of the pain. A Radiologist was consulted.(independent)
After 4 hours the patient was experiencing a minimal pain or very less pain.
Hyperthermia In a day the patient is to obtain a normal body temperature.(short term goal) Check the patient’s temperature to see if there are any changes or not. (independent).Provide fluid and tepid bath to cool. (collaborative) After 1 day of nursing intervention a normal body temperature of 37degree Celsius was obtained, the patient is no longer suffering from hyperthermia.
Disturbed sleep pattern The patient to obtain a normal sleeping pattern in Monitor the clients sleeping pattern and her usual bedtime routines. (independent) . Keep environment quiet as possible and advise her on taking hot or warm fluids before bed to ease her when sleeping.(collaborative) The clients sleep pattern was carefully monitored and a normal sleeping was achieved.
Toileting self- care deficit The patient to be able to carry out self-care on her own including elimination, cleaning up and also getting dressed.(long term goal) Assess the ability to perform self-care including elimination, bathing cleaning up and dressing. Provide a way to do a shower, clean up and getting dressed, family can train and support the client ability to self-care. (collaborative) The patients self-care abilities were observed and family members supported the client .Client was able to carry out most
Risk for infection
Reduce the risk of infection
Observe the color of the respiratory secretions
The color of the sputum was yellowish indicating respiratory infection
Fatigue
The patient to increase energy and improve wellbeing Assess frequency of fatigue, activities associated with increased fatigue, ability to perform activities of daily living (ADLs), times of increased energy, ability to concentrate, and usual pattern of activity.(Nanda Nursing Diagnosis, 2011)
The patient was monitored that she is still not capable of performing ADLs.
Imbalanced nutrition: less than body requirements. The patient to increase the nutrition by consuming adequate nourishment. Determine healthy body weight for age and height. Refer to dietitian for complete nutrition assessment. Assess client’s ability to obtain and use essential nutrients. The patient was given nutritious meals inorder to obtain essential nutrients.
Collaboration
Inorder to achieve and provide an effective care given collaboration is an important aspect. In this nursing care plan The dietitian was consulted inorder to check and implement on the diet of the patient. A physical Therapist was consulted inorder to observe the patients ability to move and assist her I mobility. Also a Radiologist was reffered to due to the pain the patient was having that is headache and sharp and throbbing pain due to coughing.
Referennce
Crisp, J., & Taylor, C. (2005). Potter & Perry’s Fundamental of Nusing. (2 nd ed.). 30-52,
Smidmore Street, Marrickville, NSW, Australia.
Gulanick, M., & Myers, J. L. (2011). Nursing Care Plans: Diagnosis Intervention and
Outcomes. 3251 Riverport Lane, St. Louis, Missouri : Elsevier.
Murray, R,B., Huelskoetter, M,W., & O’Driscoll, D, L. (1980). The Nursing Process in
Later Maturity. Englewood Cliffs, New Jersey: Prentice- Hall
Parker,S., & Clare, J. (2000). Becoming a Critical Thinker. Sydney :McLennan &Petty.
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