Introduction
Before beginning to consider what sort of information you might need to collect, we need to look at the skills that are necessary to ensure that the data analyzed are comprehensive. “The nursing process is a problem-solving framework that enables the nurse to plan care for a client on an individual basis”. (Partridge & Smith, 1987). The nursing process is not undertaken once only, because the client’s needs frequently change and the nurse must respond appropriately. It is thus a cyclical process consisting of the five stages which starts with “Assessment, Diagnosis, Planning, Implementation, and ends with Evaluation”. “ The nursing process originated in the USA and was formally introduced into the UK in 1977 when the then General Nursing Council introduced its revision of the nursing syllabus therefore it was an attempt to move nursing away from its traditional ‘task-oriented’ approach to a more scientific and individualized one”. (Marjoram & Hogston, 2007).
This case scenario is based on a productive cough. “This is part of a response group that defends the bronchi, trachea and lungs against irritation from a foreign body or excessive secretion”. (Myers, 2014). A cough is a sudden, violent expulsion of air from the lungs, which may contain a mix of mucus, cell debris, pus and microorganism. A cough is difficult to evaluate, and almost everyone has periods of coughing. Patients with a chronic cough tend to deny, underestimate or minimize their coughing, often because they are so accustomed to it that they are unaware of how often it occurs. Coughing is classified according to the time when the patient most frequently coughs.
ASSESSMENTS
“Assessment is not an easy process as it includes collecting information from a variety of sources”.(Smith, 1987). The quality of the assessment will, however, depend on one’s ability to put together all the sources at ones disposal. In assessments, signs and symptoms are been identified and so as the collection of data as subjective and objective data. Providing assessments for a client helps health professional to consider the cases introduce when undertaking a nursing assessment.
SUBJECTIVE DATA
Bio-Data:
Name: Mrs. X Age: 40 years
Sex: Female Religion: Methodists
Ethnicity: Fijian Address: Damanu Street
Marital Status: Married Occupation: School teacher
Emergency Contact: 8476001
CHIEF COMPLAIN:
Cough-3 weeks till today
Very productive cough
Sputum is yellowish in color and thick
Cough started with mild fever 3 weeks ago
Has severe cough at night
Cough is worse when taken herbal and steam in halation’s
Experience headache
Pain is sharp, throbbing and worsens when lie down
Cough relieved when in a fowlers position
Has a similar episode of cough and headache, year ago and was treated
Has a family history of asthma and diabetes
Drink grog occasionally
Smokes three rolls of cigarette in a day
Cannot mobilize around
Cannot assist itself in elimination and personal hygiene
HISTORY OF PRESENT ILLNESS
Productive cough started three weeks till today
Started when mild fever occur 3 weeks ago
Cough is worse even though when herbal and steam inhalation are provided
Pain is sharp, throbbing and worsens when she lies down
PAST MEDICAL HISTORY
Mrs. X has a similar episode of cough and headache a year ago and was treated
FAMILY MEDICAL HISTORY
Asthma
Diabetes
SOCIAL HISTORY
Mrs. X drinks grog occasionally
Smokes three rolls of cigarette in a day
ALLERGIES
Nil
FUNCTIONAL HEALTH PATTERNS
Elimination pattern- bowels and urinary elimination pattern are assisted
Activity/ Exercise pattern- sufficient energy for desired activities
Sleep/rest pattern – sleep onset problems related to productive cough
Nutritional/metabolic pattern – food or eating is discomfort due to thick mucus as well as swallowing of food which causes pain to the throat.
OBJECTIVE DATA
General appearance:
Abnormal gait
Looks tired and pale
Wearing a warm clothes in a sunny day
Vital signs:
TPR, SpO2, BP
Tachypnea
High temperature
Breathing sound
Crackling voice
DIAGNOSIS
The second stage of the nursing process is making a nursing diagnosis. “This enables the nurse to translate the information gained during the assessment and identify the nursing problems”. (Marjoram & Hogston, 2007). In order to avoid confusion, it is worth noting that ‘diagnosis’ is not a concept unique to medicine: car mechanic diagnose mechanical problems, teachers diagnosis learning difficulties, and consequently nurses diagnose nursing problems. Nursing diagnosis is a critical step in the nursing process, depends on an accurate and comprehensive nursing assessment and forms the basis of nursing care- planning. It is the end – product of nursing assessment, a clear statement of the patient’s problems as ascertained from the nursing assessment.
Nursing Diagnosis
Impaired gas exchange
Ineffective airway clearance
Risk for infection
Ineffective breathing pattern
Acute pain
Disturbed sleep pattern
Anxiety
Hyperthermia
Activity intolerance
Impaired physical mobility
PLANNING
There are two steps to the planning stage, which is ‘setting of goals and nursing intervention’. “A goal is a statement of what the nurse expects the client to achieve and is sometimes referred to as an objective”. (Nettina, 2014). In other words, goals are the intended outcomes and can be short or long term. The next stage is to plan the nursing care that will ensure the clients achieve their goals. This is where the nurse prescribes nursing actions that can then be implemented and evaluated.
IMPAIRED GAS EXCHANGE
Expected outcomes : To maintain a normal gas exchange for within 2 weeks
Long term goal: As it takes much time for normalizing gas exchange
Intervention: Assess the patient’s ability to cough effectively to clear secretions and note the quantity, color, and consistency of sputum.
INEFFECTIVE AIRWAY CLEARANCE
Expected outcomes : To demonstrates effective clearing of secretions within a week
Short term goal: As it takes only 3 days to clear out the airway
Intervention: Demonstrate effective coughing and deep breathing techniques as well as to instruct the patient to increase fluid intake.
RISK FOR INFECTION
Expected outcomes: To demonstrate a good hand washing techniques for freely infections within a week.
Short term goal: As it takes only a few days to recover from infection
Intervention: Assess the patients in washing of hands and teach other care givers to wash hands before contact with patients.
INEFFECTIVE BREATHING PATTERN
Expected outcomes: To maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate within 3 weeks.
Long term goal: As it takes longer period of time to normalize breathing pattern.
Intervention: Assess the position that the patient assumes for breathing as well as the ability to clear secretion.
ACUTE PAIN
Expected outcomes: To restore patient exhibits increased comfort and free from acute pain within 3 weeks.
Long term goal: It takes some time to normalize the acute pain
Intervention: Assess pain characteristics, quality (sharp, throbbing), location and severity as well as the patients expectation for pain relief.
DISTURBED SLEEP PATTERN
Expected outcomes: To maintain a normal sleep or rest pattern for a few days.
Short term goal : As it takes only few days to recover from being disturbed while sleeping
Intervention: Provide a quiet environment for your patient to sleep and also to promote comfort measures such as back rub and change in position as necessary.
ANXIETY
Expected outcomes: To demonstrate patient in using effective coping mechanism within 2 days
Short term goal: As it depends on how nurses cope up with their clients
Intervention: Assist the patient in developing new anxiety reducing skills, eg.relaxition and deep breathing.
HYPERTHEMIA
Expected outcomes: To maintains body temperature below 39 (102.2 F), within a week
Short term goal: As it takes a short period of time to normalize body temperature
Intervention: Assess the patient body temperature, maintain a cool environment temperature and provide an increased fluid intake.
ACTIVITY INTOLERANCE
Expected outcomes: To restore patient exhibits tolerance during physical activity within a week
Short term goal: As it takes only a few days to recover from intolerance
Intervention: Assist patients with planning activities for times when they have the most energy as well as the patients perception of effort required to perform desired activity.
IMPAIRED PHYSICAL MOBILITY
Expected outcomes: To restore patient free from complications of immobility within a week
Short term goal: As it takes only a few days to be free from impaired physical mobility
Intervention: Encourage coughing and deep breathing exercise and use suction as needed or an incentive spirometer.
Implementation
Implementation is the ‘doing’ phase of the nursing process. “This is where the nurse put into action the nursing care that will be delivered and address each of the diagnoses and their goals”. (Myers & Gulanick, 2014). The nurse will undertake the instructions written in the care plan in order to assist the client in reaching this goal. This will involve the process of teaching and helping clients to make decisions about their health.
IMPAIRED GAS EXCHANGE
Instruct client to breath slowly if hyperventilating
Instruct client to deep breath or use incentive spirometer every 1-2 hours
Consult appropriate health care provider if signs and symptom of impaired gas exchange worsen
INEFFECTIVE AIRWAY CLEARANCE
Instruct and assist client to deep breath and cough or “huff” every 1-2 hours
Perform actions to decrease pain if present in order to increase the clients willingness to move, cough and deep breath
RISK FOR INFECTION
Perform actions to prevent stasis of respiratory secretions (e.g. Assist client to turn, cough and deep breathe increases activity as tolerated).
Use good hand washing technique and encourage client to do the same.
INEFFECTIVE BREATHING PATTERN
Perform action to reduce pain in order to increase the clients willingness to move and breathe more deeply
Perform action to clear secretion
When severe pain has subsided, place client in a semi- to high fowlers position unless contraindicated; position with pillows to prevent slumping
ACUTE PAIN
Instruct and assist with patients pain
Perform action in pain relief
DISTURBED SLEEP PATTERN
Perform actions to reduce interruptions while sleeping
Ensure good room ventilation
Reduce environmental distractions
ANXIETY
Perform the action to client in coping mechanism such as encouraging and advising concerning the problems
Instruct client in order to decrease the level of anxiety.
HYPERTHEMIA
Perform patients with normal body temperature
Allow patient to live in a cool environment
ACTIVITY INTOLERANCE
Perform passive activity to help in respiratory rate of breathing
Include a physiotherapy to help in the activity
IMPAIRED PHYSICAL MOBILITY
Encourage patient to move freely and free from complications of immobility
Include a physiotherapy to help in physical mobility
EVALUATION
The final stage, evaluation, is in reality the end of the beginning and where the process in essence restarts. “Evaluation is about reviewing the effectiveness of the care that been given, which serves two purposes. (Marjoram & Hogston, 2007). First, the nurse is able to ascertain whether the desired outcome for the client has been achieved. Second, evaluation acts as an opportunity to review the entire process and determine whether the assessment was accurate and complete, the diagnosis correct, the goals realistic and achievable, and the prescribed actions appropriate.
DIAGNOSIS EXPECTED GOAL INTERVENTION EVALUATION
Impaired gas exchange To maintain a normal gas exchange for within 2 weeks Assess the patient ability to cough effectively to clear secretions and note the quantity, color and consistency of sputum. The patient was able to normalize gas exchange after 2 weeks.
Ineffective airway clearance To demonstrate effective clearing of secretions within a week • Demonstrate effective coughing and deep breathing techniques.
• Instruct the patient to increase fluid intake. The patient was able to demonstrate and clear out secretions from the airway after 3 days.
Risk for infection To demonstrate a good hand washing techniques for freely infections within a week. Assess the patients in washing of hands and teach other care givers to wash hands before contact with patients. Patient was able to normalize with infections after 5 days.
Ineffective breathing pattern To maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate. Assess the position that the patient assumes for breathing The patient was able to normalize effective breathing pattern after 2 weeks.
Acute pain To restore patient exhibits increased comfort and free from acute pain within 3 weeks. Assess pain characteristics, quality (sharp, throbbing’s), location and severity as well as the patients expectation for pain relief.
Patient feels comfortable without any acute pain after 2 weeks.
Disturbed sleep pattern To maintain a normal sleep or rest pattern for a few days • Provide a quiet environment for your patient to sleep
• Promote comfort measures, such as back rub and change in position as necessary. The patient was able to normalize with its sleeping pattern after 3 days.
Anxiety To demonstrate patient in using effective coping mechanism within 3 days. Assist the patient in developing new anxiety reducing skills, e.g. relaxation and deep breathing. The patient was able to demonstrate and achieve in effective coping mechanism after 2 days.
Hyperthermia
To maintains body temperature below 39 (102.2 F) within a week. Assess the patient body temperature and maintains a cool environment temperature.
The patient was able to normalize with its temperature after 5 days.
Activity intolerance
To restore patient exhibits tolerance during physical activity within a week.
• Assist patients with planning activities for times when they have the most energy.
• Assess the patients perception of effort required to perform desired activity. The patient was able to normalize with their physical activity after 2 days.
Impaired physical mobility To restore patient free from complications of immobility within a week. Encourage coughing and deep- breathing exercise and use suction as needed or an incentive spirometer. The patient was free from complications of immobility, thus able to practice physical mobility after 3 days.
INDEPENDENT INTERVENTIONS
Are activities that nurses are licensed to initiate on the basis of their knowledge and skills. In this case, nurses will do their own assessment to their patients and not relying to other health professionals. This includes physical care, ongoing assessment, emotional support and comfort, teaching and counseling.
ACCORDING TO THE CASE SCENARO:
Positioning of the patients so that he/ she assumes for breathing
Assist the patient in personal hygiene such as hand washing and other personal care
Assist the patient with vital signs
Helps in emotional support and in spiritual needs
Advice and encourage patient concerning the problems
COLLABORATIVE INTERVENTION
It describes the actions that the nurse carries out in collaborating with other health team members. In this case, other health professionals will help clients to improve on their health and satisfied their pain.
ACCORDING TO THE CASE SCENARO:
Physiotherapists – helps to practice normal breathing for the client
Dieticians – to advice on the diet given to the clients ( soft diet).
Lab technicians- to test for the secreted sputum to evaluate the problems.
REFERENCE
Marjoram, A. B., & Hogston, R. (2007). : Foundation of Nursing: Problem in Adult
Care. Australia: Macmillian P.
Myers, L. J., & Gulanick, M. (2014). Nursing care Plans: Diagnoses, Interventions, and
Outcomes. (8th ed). Elsevier Australia: Patterson J.
Nettina, M. S. (2014). Lippincott Manual of Nursing Practice. (10th ed). Wolters
Kluwer.
Partridge, B., & Smith, W. (1987). Handbook of Nursing Problem in Adult Care.
Australia: McGougan K.