ASSESSMENT TWO
TOPIC: NURSING PROCESS
Introduction
The nursing process is utilized as a common framework for settling on practice choices in nursing about diagnosis and treatment of human reactions to wellbeing and sickness. (Crisp & Taylor, 2009).Nursing process is constantly changing as per patients requirement so creativity is one of its fundamental attributes. Creativity includes unique speculation where the nurse considers the patient as well as the patients background. It is a systematic approach of nursing care and becomes a blueprint for care. The process includes general specific critical thinking competencies in a way that focuses on a particular clients unique needs.
The Nursing Process has five steps .It includes assessment where a nurse systematically collects, verify, analyses and communicate data about a client .The two types of data obtained by the nurse during assessment is subjective and objective data. Subjective data is the clients perception about their health status whereas objective data are the observations a nurse makes upon clients admission from head to toe. Nursing diagnosis involves the outcome of the assessment made. A nursing diagnosis is formulated in order to identify health problems involving the client and family and to provide direction for delivering nursing care. Critical thinking skills is also important for a nurse to rank diagnoses in order of importance. Planning is a category of nursing behaviour in which client centred goals and expected outcomes are established. Priorities are set during planning. Implementation begin after the care plan has been developed. The nurse selects interventions that supports the clients health status. The last step of nursing process is Evaluation which measures the clients’ response to nursing actions and the clients’ progress towards achieving goals. It is the most important step in nursing process because it identifies the effectiveness of nursing practice.
The advantage of nursing process is that it establishes a holistic approach to patient care where family members are involved in aiding in recovery. It helps nurses plan care with individual client where all planned activities are carried out systematically. The establishment of a professional relationship between the nurse and client enhances trust. It also allows the nurse identify the need for continuity of care for the patient after hospital admission.
This case study based on the given case scenario will elaborate more on the nursing process in order to help Mrs X recover.
Assessment
Subjective Data
Bio Data
Name: Mrs X
Age: 40 yrs
Sex: Female
Religion: Christian
Ethnicity: I–taukei
Marital status: Married
Occupation: School Teacher
Address: Damanu Street
Emergency Contact: 9190045/8771019
Chief Complain:
Mrs X presented to GOPD with productive cough for three weeks.
History of Present illness
She stated that the cough started when she had mild fever three weeks ago and severe at night. The contents of her sputum she noticed was yellow in colour. She also stated that she started to experience headache when she coughs for the last three days, the pain was sharp, throbbing and worsens when she lies down. The cough is relieved when she is in a fowler’s position. Due to her productive cough her daily living has also been affected. She cannot mobilise around to perform daily household activities such as cooking. She also mentioned that she has always being assisted by her aunty for her elimination and personal hygiene.
Past Medical History
She stated that she had a similar episode of cough and headache a year ago.
Family Medical history
She mentioned that her family has history of asthma and diabetes.
Social History
She mentioned that she drinks grog occasionally and smokes three rolls of cigarettes in a day. The cough was worse but she stated that she managed with herbal and steam inhalation.
Functional Health Patterns
– She cannot mobilise to preform daily household activities.
– She has always been assisted by her aunty for her elimination and personal hygiene daily.
Objective Data
Observed appearance and behaviour while talking and resting: -Restlessness
-Looked tired and exhausted
-Crackle in her voice
-Very poor personal hygiene
Palpated skin: -Warm, dry skin
Obtained vital signs: -High blood pressure
-High temperature
-Increase pulse rate
-Decrease respiration
Auscultation of lungs: -There was a decreased in her breath sounds
-Wheezing sound
-Coarse cracker
Nursing Diagnosis
1) Ineffective airway clearance
2) Ineffective breathing pattern
3) Impaired gas exchange
4) Risk for suffocating
5) Hyperthermia
6) Risk for infection
7) Disturbed sleep pattern
8) Impaired comfort
9) Impaired physical mobility
10) Activity intolerance
Planning (Expected Outcome)
1) Ineffective airway clearance.
Long term Goal
-Client will maintain clear open airways as evidenced by normal breath sounds, normal rate and depth of respirations.
Short term Goal
-Client will be able to effectively cough up secretions after treatments and deep
Breaths.
2) Ineffective breathing pattern.
Short term Goal
-Client will maintain an effective breathing pattern.
Long Term Goal
-Client remains free of signs and symptoms of hypoxia.
3) Impaired gas exchange.
Short term Goal
-To maintain a normal gas exchange in a day.
4) Risk for suffocating.
Short term Goals
-Client will be able to demonstrate behaviours, lifestyle changes to reduce risk factors and protect self from suffocating.
-Client verbalise understanding factors that contribute to possibility of suffocating and take steps to correct situation.
5) Hyperthermia
Short term Goal
-Client will regain normal range of body temperature within next 24hours
-Fluid and electrolyte balance will be maintained during next 3 days.
6) Risk for infection.
Long term Goal
-Client remain free of infections.
Short term Goal
-The client will carry out proper hand washing after meals and after toilet visits.
7) Disturbed sleep pattern.
Short term Goal
-The client will wake up less frequently during night.
-Client will restore normal sleep pattern.
8) Impaired comfort.
Short term Goal
– In four hours the client will be able to tolerate felt pain and also verbalize decrease in pain felt.
Long term Goal
-After a week the patient will feel no pain at all.
9) Impaired physical mobility.
Long term Goal
-Client will be able to perform physical activity independently.
-Client is free of complication of immobility.
-Client demonstrates use of adaptive techniques that promote ambulation and transferring.
10) Activity intolerance.
Long term Goal
-Client reports ability to perform required activities of daily living.
Short term Goal
-Client verbalizes and uses energy conservation techniques.
Implementation (Interventions)
1) Ineffective airway clearance
-Assess airway for patency.
-Loosen Clients Clothing from neck or chest and abdominal area.
-Teach coughing breathing and splinting techniques.
2) Ineffective breathing pattern
-Assess respiratory rate, rhythm and length.
-Assist Client in use of respiratory devices and techniques.
-Teach Clients to pace activities and to avoid unnecessary tasks when dyspnoeic.
3) Impaired gas exchange.
-Assist Client in sitting position.
-Teach breathing exercises.
4) Risk for suffocating.
-Teach Client risk factors that leads to suffocating.
5) Hyperthermia.
-Temperature was monitored every four hours.
-Client was instructed to reduce external covering and keep clothing and bedclothes dry.
-Instruct Client to increase oral fluids of choice.
6) Risk for infection.
-Monitor signs of actual infect such as redness, swelling, increase pain, elevated temperature, colour of respiratory secretions and appearance of urine
-Advice client to avoid use of alcohol and smoking
-Teach the Client or caregiver to wash hands often especially after toileting, before and after meals and after administering health care.
7) Disturbed sleep pattern.
-Assess clients’ sleeps pattern and usual bedtime rituals.
-Advice client to avoid use of alcohol and smoking
– Keep environment quiet.
8) Impaired comfort.
-Administer pain medication and monitor vital signs.
-Promote comfort by making sure client is positioned properly and Client should be encourage to take deep breathing exercise.
9) Impaired physical mobility.
-provide a safe environment; bed vials up, bed in down position necessary items close by.
-Encourage and facilitate early ambulation and the need for assistive devices.
10) Activity intolerance.
-Assess the clients’ ability to perform ADL’s effectively and safely on daily basis.
-Encourage and facilitate early ambulation and the need for assistive devices.
Evaluation
1) Ineffective airways clearance
-Client was able to cough up secretions within a week.
2) Ineffective breathing pattern
-Client maintained an effective breathing pattern in three days.
3) Impaired gas exchange
-Client maintained a normal gas exchange a day
4) Risk for suffocating
-Client was able to demonstrate behaviours and other factors within two days
-Client was able to cough up secretions within three days
5) Hyperthermia
-fluid and electrolyte balance will be maintained during next three days.
-Temperature was rewarded as normal in 24 hours.
6) Risk for infection
-Client was able to carry out proper hand washing before and after meal.
7) Disturbed sleep pattern
-client does not frequently wake up at night after two days.
-Patient restore normal sleep pattern in week
8) Impaired comfort
-Client was able to tolerate pain in limited hours
-No more pain was felt in a week
9) Impaired physical mobility
-Client was able to demonstrate use of adaptive techniques that promotes ambulation and transferring after a week.
10) Activity intolerance
-Client was able to perform activities independently after three weeks.
Nursing Diagnosis Expected Outcome Nursing Interventions Evaluation
Ineffective airway clearance Client will maintain clear, open airways evidence by normal break sounds, normal rate and depth of respiration and ability to effectively cough up secretions after treatment and deep breaths. -Assess airway for patency.
-Loosen Clients clothing from neck or chest and abdominal area.
-Teach coughing breathing and splinting techniques. -Client was able to cough up secretions within a week.
Ineffective breathing pattern -client will maintain an effective breathing pattern.
-Client remains free of signs and symptoms of hypoxia -Assess respiratory rate, rhythm and length.
-Assist patient in use of respiration devices and techniques.
-Teach Clients to pace activities and to avoid unnecessary tasks when dyspnoeic. -Client maintained an effective breathing pattern in three days.
Impaired gas exchange -To maintain a normal gas exchange in a day -Assist Client in sitting position.
-Teach breathing exercises. -Client maintained a normal gas exchange in a day.
Risk for suffocating -Client will be able to demonstrate behaviours, lifestyle changes to reduce risk factors and protect self from suffocating.
-Client verbalise understanding of factors that contribute to possibility of suffocating and take steps to correct situation. – -client was able to demonstrate behaviours and other factors within two days.
-client was able to cough up secretions within three days.
Hyperthermia -Fluid and electrolyte balance will be maintained during next three days.
Client will regain normal range of body temperature within next twenty four hours.
-Temperature was monitored every four hours.
-Client was instructed to reduce external covering and keep clothing and bedclothes dry.
-Instruct client to increase oral fluids of choice. -fluid and electrolyte balance was maintained in three days
-Temperature was recorded as normal in 24 hours.
Risk for infection -Client remains free of infections
-The client will carry out proper hand washing after meals and after toilet visiting. -Monitor signs of actual infect such as redness, swelling, increased pain, elevated temperature, colour of respiratory secretions and appearance of urine.
-Teach the Client or caregiver to wash hands often especially after toileting, before and after meals and after administering self-care. -Client was able to carry out proper hand washing before and after meals in a day.
Disturbed sleep pattern -The client will wake up less frequently during night.
-Client will restore normal sleep pattern. -Assess clients sleep pattern and usual bedtime rituals.
-Advice client ta avoid use of alcohol and smoking.
-Keep environment quite. -Does not frequently wake up at night after two days.
-Client restores normal sleep pattern after a week.
Impaired comfort -In four hours the client will be able to tolerate felt pain and also verbalised decrease in felt pain.
-After a week the Client will feel no pain at all. -Administer pain medication and monitor vital signs.
-Promote comfort by making sure Client is positioned properly and Client should be encourage to take deep breathing exercise. -Client was able to tolerate pain in limited hours.
-No more pain was felt in a week.
Impaired physical mobility -client will be able to perform physical activity independently.
-client is free of complication of immobility.
-client demonstrates use of adaptive techniques that promotes ambulation and transferring. -Assess the client ability to perform ADLs effectively & safety on a daily basis.
-Provide a safe environment: bed rails up, bed in down position, necessary items close by.
– Encourage and facilitate early ambulation and the need for assistive devices. -Client was able to demonstrate use of adaptive techniques
Activity intolerance
-client reports ability to perform required activities of daily living.
-client verbalizes and uses energy conservation techniques.
–
-Client was able to perform activities independently after three weeks.
Short term goal
To provide nursing care for relieving on productive cough within days.
Long term goal
To provide holistic care to client and family so that the client will be able to recover and proceed in normal life.
Independent interventions
• Vital signs was monitored every four hours.
• Mrs X was positioned in a way that makes her comfortable every two hours to avoid any complication.
• Tepid sponge bath was done due to high temperature.
• Personal hygiene habits was taught to Mrs X. Tooth brushing after meals, applying body deodorant and keeping the whole body looking fresh to aid looking well.
Collaborative Interventions
• Mrs X was referred to a Radiologist for chest x-ray to exclude other causes of productive cough such as lung cancer and Tuberculosis.
• Dietician was called to address the balance diet – 3 food groups & servings. Also dietician counselled client regarding SNAP (smoking, nutrition, alcohol and Physical Activity). Family members was involved in addressing the diet issue.
• For exercising purposes a physiotherapist was called to help the client in breathing and positioning that will aid in breathing.
• Blood samples were taken to the lab technician to rule out any infection.
Reference
Urden, D.L., Stacy, M.K., & Lough E.M. (2014). Critical Care Nursing: Diagnosis and
Management. (7th e.d). St Louis, Missouri: Elsevier Mosby.
Jarvis, C. (2012). Physical Examination & Health Assessment. (7th e.d). St Louis,
Missouri: Elsevier Saunders.
Crisp, J., & Taylor, C. (2009). Fundamentals of Nursing. (3rd e.d). NSW: Elsevier Mosby
Gulanick, M., & Myers, L.J. (2014). Nursing Care Plan: Diagnosis, Interventions, and
Outcomes. (8th e.d). Philadelphia: Elsevier Mosby.