Introduction
Nursing process is a five step methodical basic leadership strategy concentrating on recognizing and treating reactions of people or gatherings to genuine or potential adjustments in health. Includes assessment, nursing diagnosis, planning usage and evaluation. The first step of nursing procedure is assessment, which compromise of perception. It requires gatherings of both objective and subjective data. The second step, nursing diagnoses about individual, family or group nursing reaction to real or potential life processes. Gives the essential to determine the nursing mediation to accomplish for which the medical caretaker is accountable.
The third step is planning, which requires foundation of result criteria for patients care. The fourth step is implementation; this step includes showing those exercises that will be furnished to and with the patient to permit accomplishment of the normal results of care. Evaluation is the fifth and last step of nursing process. It requires examination of the patient’s current state with the expressed expected results and results in modification of the arrangement of consideration to improve progress towards the expressed results.
All the point when a patient enters the clinical setting, the nurse uses the progression of nursing procedure to move in the direction of accomplishing sought results and objectives distinguished for the client. The viability of the arrangement of consideration is assessed by finding out regardless of whether subjective have been achieved or whether issues stay at the season of discharge. If issues are unresolved, plans should be made for further take up, including assessment, additional issue and need identification, alterations of craved results and objectives and changes in mediations in the following consideration setting although a few medical caretakers see the nursing process as separate, progressive steps, the components are really interrelated.
Assessment
Subjective Data
Name: Mrs. X
Age: 40 Years
Sex: Female
Religion: Christian
Ethnicity: I-Taukei
Marital Status: Married
Occupation: Teacher
Address: Damanu Street
Emergency Contact: xxxxxxxxx
Chief Complain
Cough: 3 Weeks
History of Present Illness
Mrs. X stated that the cough started when she had mild fever 3 weeks ago and was severe at night. She had a sharp and throbbing pain and also thick and yellowish sputum.
Aggravating Symptoms
The cough gets worse when she lies down.
Precipitating Factor
The cough is relieved when she is in a Fowler`s position.
Associated Symptoms
Cough was associated with headache.
Past Treatment and Evaluation of Symptoms
She had a similar episode of cough and headache a year ago.
Effects of the Symptom on Daily Activities
Due to the illness, her daily living has also been affected. Mrs. X cannot mobilize around to perform daily household activities such as cooking .She is also assisted by her Aunty for her elimination and personal hygiene performance daily.
Past Medical History
Mrs. X had a similar episode of cough and headache a year ago.
Family Medical History
Mrs. X`s family had a medical history of Asthma and diabetes.
Social History
Mrs. X states that she drinks Grog occasionally and smoke three rolls a week
Mrs. X has difficulty in doing her chores so she is assisted by her Aunty for elimination and personal hygiene and also aids her in cooking and helping her in mobilizing.
Objective Data
General Appearance- Abnormal Gait
-Looks Tired
-Wearing warm clothes on a sunny day
Vital Signs- TPR, Blood Pressure
-Tachypneoa
-High Temperature
Crackling Voice
Diagnosis
Ineffective Airway Clearance
Inability to clear secretions from the respiratory tract to maintain a clear airway
Expected Outcome
Mrs. X will maintain clear open airways as evidenced by normal breath sounds, normal rate and depth of respirations and ability to effectively cough up secretions after treatments and deep breaths.
By the end of one week the patient will fully recover and maintain a normal breathing or airway clearance.
Impaired Gas Exchange
Excess in oxygenated or carbon dioxide elimination at the alveoli capillary membrane.
Expected Outcome
Patient maintains optimal gas exchange, will fully recover and will maintain a normal gas exchange pattern within two weeks.
Ineffective Breathing Pattern
Inspiration or expiration that does not provide adequate ventilation.
Expected Outcome
Patients breathing pattern is effectively maintained as evidenced by relaxed breathing at normal rate and depth and no complaints of Dyspnea.
Assess the position that the patient assumes for breathing at normal rate, assess the ability to clear secretions .Assess sputum for quantity, color, consistency and odor. If sputum is discolored, send the specimen for culture and sensitivity as appropriate.
Activity Intolerance
Insufficient physiological energy to endure or complete required daily activities.
Expected Outcome
Patient maintains activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity as well as absence of shortness of breath, weakness and fatigue.
Patient verbalizes and uses energy conservation techniques.
Anxiety
Vague uneasy feeling of discomfort or dead accompanied by an autonomic response, a feeling of apprehension caused by anticipation of danger.
Expected Outcome
Patient is able to recognize signs of anxiety.
Patient will be able to demonstrate positive coping mechanisms after two weeks.
Impaired Physical Mobility
Limitation in independent physical movement of the body of one or more extremities.
Expected Outcome
Patient performs physical activity independently and will be free of complications of immobility as evidenced by intact skin and normal bowel pattern.
Disturbed Sleep Pattern
Time limited disruption of sleep amount and quality.
Expected Outcome
Patient achieves optimal amounts of sleep as evidenced by rested appearance, verbalization of feeling rested, and improvement in sleep pattern.
Acute Pain
Unpleasant sensory and emotional experience arising from actual or potential tissue damage.
Expected Outcome
Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.
Risk for Infection
At increased risk for being invaded by pathogenic organisms.
Expected Outcome
Patient remains free of infection as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions and tubes.
Diagnosis
Expected Outcomes Implementations Evaluations
Ineffective Airway Clearance Maintains clear, open airways as evidenced by normal breaths sounds, normal respiration rate and deep breaths
By the end of one week the patient will fully recover and will maintain a normal airway clearance. Use pulse oximetry to monitor oxygen saturation, assess arterial blood gases (ABG`s) Patient was able to maintain a normal airway clearance.
Impaired Gas Exchange Maintains optimal gas exchange as evidenced by ABG`s within the patients usual range, alert responsive mentation in level of consciousness , relaxed breathing, baseline HR Assess the lungs for areas of decreased ventilation and the presence of adventitious sounds Monitor the gas exchange pattern
Ineffective Breathing Pattern Maintains an effective breathing pattern.
Maintains an effective breathing after two weeks. Assess sputum for quantity, color, consistency and odor Maintains a normal breathing pattern
Activity Intolerance
Maintains activity level within capabilities as evidenced by normal heart rate and blood pressure. Assess the need for ambulation aids, bracing, cane, walker, equipment modification for ADL`s Verbalizes and uses energy conservation techniques.
Anxiety Uses effective coping mechanism Maintain a calm manner Maintains a feeling of stability in a calm and nonthreating atmosphere
Impaired Physical Mobility Performs physical activity independently or with assistive devices as needed Evaluate the need for assistive devices. Monitor the physical mobility
Disturbed Sleep Pattern Achieves optimal amounts of sleep as evidenced by rested appearance, verbalization in sleep pattern
Recommend an environment conducive to sleep or rest. E.g. quiet, comfortable temperature, ventilation, darkness, closed door. Patient was able to sleep properly
Acute Pain Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain Evaluate the patients response to pain and pain management strategies Patient was relieved from the pain
Long Term Goals
Fully recover and will maintain a normal gas exchange pattern within two weeks.
Maintains blood pressure, respiratory rate, and heart rate within two weeks.
Maintains optimal gas exchange within ten days.
Verbalizes adequate relief of pain or ability to cope with incompletely relieved pain within three weeks.
Breathing pattern is effectively maintained within two weeks.
Short Term Goals
Verbalizes and uses energy conservation techniques.
Recognize signs of anxiety.
Demonstrates coping mechanism.
Performs physical activity independently.
Independent Intervention
Vital signs
Medications
Positioning the Client
Elimination
Dependent Intervention
Medications
X-Rays
Acupuncture
Collaborative Intervention
Nutrition
Exercise Patterns
Administer medications as prescribed
Monitor oxygen saturation, assess arterial blood gases (ABG`s)
Monitor Hgb levels
(Approximately: 1,350)
Reference
Carpenito LJ (2009) Nursing diagnoses: application to clinical practice, (ed. 12.). Philadelphia, JB: Lippincott.
What is nursing process? Retrieved on 22nd April from www.medilexicon.com/medicaldictionary.php?t=61900
Gordon M (2007) Nursing diagnoses: process and application, (ed.11.). St. Louis, Mosby.
NANDA International 2012-14: NANDA-I nursing diagnoses: definitions and classifications. Philadelphia, NANDA-I.