Introduction
Nursing Process is a method of providing individualised nursing care that mainly focuses on identifying and treating any alteration in health to individuals of groups. There are five phases in the nursing process.
Assessment
The systematic and continuous collection, validation of client data. The information gathered needs to be examined to obtain all the necessary facts to determine the clients health status and to describe health status and to describe strengths and problems. Information collected can be medical assessment, subjective data and objective data.
Diagnosis
Is a statement that describes the client actual or potential response to a health problem, it is 2obtained from the data collected. It also determine which problem can be resolved through independent intervention, in which problem require intervention that must be prescribed by physicians.
Planning
The establishment of client- centred goals and expected outcomes and nursing interventions are selected to achieve the goals and outcomes of care.
Implementation
Describes action necessary for achieving the goals and expected outcomes of nursing care are initiated and completed. This includes teaching,monitoring,further assessing and reviewing of nursing care plan.
The last step of the nursing process that measures the clients responses to nursing actions and the clients progress towards achieving goals. It is the critical phase as it supports the basis of the usefulness and effectiveness of nursing practices which is client driven and centred
The case study focuses on a female client, Mrs X, who is 40 years of age and school teacher by profession. The client came into General Outpatient Department with complaints of cough for 3 weeks. Herbal medication and steam inhalation was practiced but condition was still not improved.
Subjective Data
Biodata: Name: Mrs X
Age: 40yrs
Sex: Female
Marital Status: Married
Occupation: School Teacher
Residential Address: Damanu St
Chief Complaint
Patient came in with complaints of productive cough for 3 weeks.
History of Present illness
Onset
Cough started from a mild fever for 3 weeks and is usually severe at night.
Character of the symptom
Patient notices the content of her sputum to be yellow in colour and thick.
Aggravating symptoms
The symptom worsens when she lies down.
Client experiences head-ache for the last 3 days, character of pain is sharp and throbbing.
Past treatment and evaluation of the symptom
Had a similar episode of cough and head-ache a year ago and was treated
Courses of the symptom
Clients cough has worsen even though she managed to use herbal and steam inhalation.
Effects of the symptom on daily activities
Client has difficulty to mobilise around to perform daily household activities such as cooking, and is also assisted with Elimination and Personal hygiene daily by an aunty.
Family Medical History
Patient has a family history of Diabetes and Asthma.
Social History
Client drinks grog occasionally and smokes 3 rolls of cigarettes in a day.
Functional Health Pattern
Health Perception- Health Management Pattern
The main causes of cough for client is due to her smoking.
Elimination Pattern.
The clients passes urine and bowel normally with assistance.
Activity- Exercise Pattern.
Client cannot mobilise around so there will be difficulty to do activities of daily living.
Sleep and Rest Pattern.
Normally goes off to bed at 9pm but in Fowlers Position as that may relieve the cough.
Self-Perception and Self Concept Pattern.
Client is unable to do daily household chores and that has really affect the client’s role as a mother.
Role-Relationship Pattern
Client live with nuclear family. Role as a mother cannot be played since she is assisted around the house.
Objective Data
General Appearance
• 40 year- old moderately built lady presents to the G.O.P.D for medical check up. Patient appears stated age; is well dressed appropriate to weather, not groomed. Alerted and oriented to place. Client coughs and producing crackling sound. Able to hear secretions on throat when client inhales. Unsteady gait. Speech is clear. Smells of cigarettes.
Vital Signs.
Height-75cm
Weight-65kg
Blood Pressure- normal
Temperature- normal
Pulse- Tachycardia
Respiration- Tachypnoea.
Physical Assessment
Integumentary
Skin brown in colour, warm and dry , good turgor with no lesions or abrasions.
Is intact, nails pink with good capillary refill.
HEENT
Head and Neck- erect, midline. No lesions. Facial features symmetrical. Carotid pulse palpable well.
Eyes- colour vision intact, Difficulty noted with far vision. Eyes clear and bright and blink, no eye-lid abnormalities.
Eyes, Nose, Throat- Skin intact, no masses or lesions. External canals clear without redness, swollen.
Nares patent- able to differentiate familiar odors, no discharge, septum intact. Crackling sounds heard.
Mouth
Lips, gums appears to be blackish. All teeth present but with discolouration of enamel, sense of taste varies.
Respiratory
Tachypnoea present. Trachea mid-line. Over expansion of lungs. Crackles and Stertor sounds heard during Auscultation.
Cardiovascular
Tachycardia present.
Abdomen
Abdomen soft,rounded,no masses or pulsations .
Musculoskeletal
Normal spinal curvature, joints and muscle symmetrical. Bilateral knee pain. Absence of range of motion.
Neurological
Alert,awake.oriented to time and place, unsteady gait, unable to bend knees due to pain. Sensitive to patellar reflex.
Formulating Nursing Diagnosis
1. Activity Intolerance
2.Risk of Infection
3.Impaired Physical Mobility
4.Ineffective Airway Clearance
5.Altered Role Performance
6.Pain
7.Self Care deficit
Expected Outcome
1. Activity Intolerance
Patient will be able to do normal activities independently.
2. Risk of infection
The client will be free of infection.
3. Impaired Physical Mobility
The client will regain optimal mobility before discharge
4. Ineffective Airway Clearance
To maintain an effective airway before discharge
5. Altered Role Performance
The client will be able to perform own roles normally
6. Pain
The client will experience relief or reduced pain to be able to perform self- care activities within own capabilities before discharge to home
Intervention
1. Activity Intolerance
Short term goal
– Assist with range of motion
– Monitor and documenting changes seen
2. Risk of Infection
Long term goal
– Monitor vital signs
– Assess clients for any sign of infection
– Note sputum characteristics
-Teach clients to turn, cough and deep breath.
3. Impaired Physical Mobility
Long term goal
-Assist client to perform Range of Motion in bed
– Assist client to follow Physiotherapists instruction regarding transfer, ambulating and use of walker.
4.Ineffective Airway Clearance
Short term goal
-Positioning
-Teach client on breathing exercises
-Monitor respiration rate
-Monitor oxygen saturation
5.Altered Role Performance
-Teach client to be role oriented
-Close monitoring of client
6.Pain
Short-term goal
-Assess the seven characteristics of pain(quality,location,onset,duration)
-Teach client about the pain scale
-Administer prescribed medication and observe for relief
-Implement alternative comfort measures if needed e.g reposition with pillows, therapeutic touch.
7.Self-Care Deficit
Short-term goal
-Assess clients ability to perform activities of daily living observing strengths and weakness.
-Help client to acknowledge level of dependence in activities that require assistance.
-Collaborate with client on the best way to perform activities of daily living such as bathing, dressing and toileting.
-Encouragement and praise as client works to attain independence.
Evaluation
1.Activity Intolerance
-Patient is able to do activities independently
2.Risk of infection
-The client will be adhere of the signs and symptoms of infection after discharge.
3.Impaired Physical Mobility
-The client is able to walk in hospital corridors three times daily with minimal assistance.
4.Ineffective Airway Clearance
The client has able to inhale and exhale without any difficulties.
5.Altered Role Performance.
Patient is able to carry out roles effectively with minimal assistance.
6.Pain
The client will require less comfort measures to control the pain.
7.Self-Care Deficit
The client is able to attend to personal hygiene, toileting by self.
Nursing Diagnosis Expected Outcome Nursing Intervention Evaluation
1.Activity Intolerance -Patient will be able to do normal activities independently within 1 week. Short term goal.
-Assist with range of motion.
-Monitor and document changes seen. Patient is able to do activities independently.
2.Risk of Infection -The client will be free of infection. Long term goal.
-Monitor vital signs.
Assess client for any sign of infection.
-Note sputum characteristics.
-Teach client to turn ,cough and deep breath.
Collaborative Intervention
-sputum specimen to be sent to laboratory for testing. The client will adhere of the signs and symtoms of infection after discharge.
3.Impaired Physical Mobility The client will regained optimal mobility before discharge. Long term goal
-Assist client to perform range of motion.
-Collaborative Intervention
-Assist client to follow physiotherapists instruction regarding transfer,ambulating and use of walker. -The client is able to walk the hospital corridors three times daily with minimal assistance.
Ineffective Airway Clearance -To maintain an effective airway before discharge. Short term goal.
-Positioning
-Teach client on breathing exercise.
-Monitor respiration rate.
-Monitor oxygen saturation.
Collaborative
-For chest x-ray to rule out any abnormality. -The client is able to inhale and exhale normally without any difficulties.
5.Altered Role Performance. -The client is able to perform own roles normally. Short term goal.
-Teach client to be role oriented.
-Close monitoring of client. -Patient is able to carry out roles effectively with minimal assistance.
6.Pain -The client will experience relief or reduced pain to be able to rest comfortably. Short term goal
-Assess the seven characteristics of pain.
-Administer prescribed medication and observe for relief.
-Implement alternative measures if needed e.g reposition of pillows, therapeutic touch. -The client will require less comfort measures to control the pain.
7.Self-Care Deficit The client will be able to perform self-care activities within own capabilities before discharge to home. Short term goal
-Assess clients ability to perform activities of daily living-observing strengths and weakness.
-Help client to acknowledge level of dependence in activities that requires assistance.
-Collaborate with client on the best way to perform activities of daily living, such as bathing, dressing and toileting. -The client is able to attend to personal hygiene and toileting by self.
Reference
Crisp.,& Taylor.(2012) Fundamentals of Nursing (3rd ed.). Elsevier, Australia.
Drauna,U.(2016), Nursing Practice, Lectures delivered at Sangam College Of
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Lynn,M,J.,& Kizilay E,P.(2014) Foundation of nursing practice;A nursing process
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Treas,S,L.,& Wikinson,M,J.,(2014) Basic Nursing; concepts and reasoning
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