INTRODUCTION
Nursing process is a sorted out orderly strategy for giving individualized nursing mind that centers after recognizing and treating remarkable reactions of individual or gatherings to real or potential change in wellbeing. (Nursing process, 2016). Nurses apply the nursing process as a competency when delivering client care. The nursing process consists of five steps: assessment, diagnosis, planning, implementation and evaluation. The process is a systematic approach used by nurses to gather client data, critically examine and analyze the data, identify the client’s response to a health problem, design expected outcomes, take appropriate action and evaluate whether the action is effective. The nursing process is a systematic and comprehensive approach for nursing care. (Crisp & Taylor, 2005)
The first phase of the nursing process is assessment. Before the nurse can plan the patient’s care, she must identify and define the patient’s problems. This phase includes collection of data about the health status of the patient and ends with the nursing diagnosis, a statement of the patient’s problem. The planning phase is the second phase and it begins with the nursing diagnosis, which is made by collecting and evaluating data that have implications for nursing actions. Once nursing intervention has been determined and the planning phase completed implementation begins which is the third phase. Nurse continues to collect and assess data and plan and evaluate care while implementing the care plan. Implementation is the actual giving of nursing care. The final but continuous phase of the nursing process is evaluation or appraisal of the care given. Evaluation of the patients’ progress is based on a comparison of the outcome of care given with the outcome to be achieved by the nurse, health care team, patient or family as stated in the objectives of the care plan. (Marriner, 1979).
In this assignment the case scenario talks about admitting a patient who has come to the hospital with a cough. Mrs. X is a 40 year old school teacher who has come in with a productive cough for three weeks and is getting worse and wants to be treated as soon as possible.
ASSESSMENT
1. SUBJECTIVE DATA:
Bio Data:
NAME: Mrs. X OCCUPATION: School teacher
AGE: 40 MARRITAL STATUS: Single
SEX: Female ADDRESS: Damanu Street
RELIGION: Christian ETHNICITY: I -taukei
EMERGENCY CONTACT: 95432219(Aunt)
Chief Complain:
Cough for three weeks
History Of Present Illness:
Have a productive cough for three weeks now and notices the contents of the sputum to be yellow in color and thick. Started when having a mild fever three weeks ago and is severe at night. The cough is worse even when managed with herbal and steam inhalations. Experience headache when coughing. The pain is sharp, throbbing and worsens when lying down. The cough is relieved when she is in a fowler’s position. Cannot mobilize around to perform household activities such as cooking.
Past Medical History:
Similar episode of cough and headache a year ago and was treated.
Family Medical History:
Asthma and diabetes
Social History:
Smokes three rolls of cigarette a day and drinks grog occasionally
Medications and Allergies:
Herbal and steam inhalations.
No allergies
Functional Health Pattern:
Assisted by her aunty for elimination and personal hygiene daily
2. OBJECTIVE DATA:
Mrs. X looks tired and is in pain. Not properly dressed and is still in her nighties with her hair looking messy. Vital signs are abnormal with an increase in temperature, pulse and blood pressure and decrease in respiration rate. Dark circles under the eyes and have puffy eyelids. Has difficulty in breathing properly.
DIAGNOSIS
A. Impaired gas exchange
B. Ineffective breathing pattern
C. In effective airway clearance
D. Activity intolerance
E. Disturb sleep pattern
F. Hyperthermia
G. Acute pain
H. Dressing self-care deficit
I. Bathing self-care deficit
J. Toileting self-care deficit
PLANNING:
GOALS/OUTCOMES
A. Maintain unlabored respirations at 12-20 minutes within four days
B. Patient maintains normal breathing pattern effectively with the normal range within within two days.
C. Maintain normal respiratory rate and clear breath sounds within three days
D. Patient is able to perform basic activities without excessive exhaustion or loss of energy and absence of shortness of breath within one week.
E. Restore proper sleeping pattern within four days.
F. Maintain normal vital signs especially normal temperature rate within 24hrs.
G. The patient will be able to mobilize within 48hrs after taking pain relieve medications as ordered.
H. The patient will be able to demonstrate increased ability to dress/groom within three days.
I. Patient will be able to perform bathing independently within three to four days.
J. Patient will be able to do toileting independently within three days.
NURSING INTERVENTION:
A. Assess respirations noting the quality, rate, rhythm, depth, breathing effort and use of accessory muscles.
B. Auscultation of breath sounds every 2hrs
C. Position client for easy breathing i.e. elevate head of the bed to a semi-fowler’s position and reposition at least every 2hrs.
D. Assess the patient’s level of physical activity and mobility and assess the need for ambulation aids: bracing, care, and walker.
E. Assess patient’s sleep pattern and changes and frequency by means of observation of the patient while sleeping and awakening.
F. Monitor temperature every 2hrs and monitor signs of dehydration.
G. Assess the patient’s pain level every 2hrs while patient is awake until patient’s pain rating is less than 4 on 1-10 scale.
H. Provide dressing aids as necessary and lay clothes out in order which they will be needed to dress.
I. Assess the ability to perform bathing independently and encourage the family to be involved in caring and monitoring the client and instruct patient to select bath time when he or she is rested and unhurried.
J. Assist in offering bedpan or place patient on toilet every one-one an half hours during day and three times during night.
EVALUATION:
A. Unlabored pain had been maintained and the patient breathing pattern has been normalized.
B. Patient’s respiratory rate remains within established limits.
C. Clear breath sounds has been produced and the normal respiratory rate has been maintained.
D. Patient is able to ambulate to the room door and back to the bed without any abnormal changes in vital signs.
E. After a few days of nursing intervention the patient is able to display improvement in sleeping pattern as evidenced by: the patient’s ability to go to sleep without being easily awakened and the presence of eye bags have been minimized or have gone.
F. Patient’s normal temperature rate has been maintained and also other vital signs.
G. Patient is able to mobilize independently
H. Mrs. X has dressed/groomed herself independently.
I. Mrs. X is able to bath herself without needing an assistant.
J. Mrs. X is able to go to the toilet by herself.
INDEPENDENT INTERVENTIONS:
As Mrs. X’s caregiver there are many independent interventions provided for her full recovery and sent home not more than two weeks. Monitoring of her vital signs every 2 or 4hrs, so that changes can be identified and noted down. Mrs. X came in without being able to mobilize, so assistance in ambulation is being provided. Also assisting in the offering of bedpan in eliminating is being provided and assistance in personal hygiene is given for her quick recovery.
COLLABORATIVE INTERVENTIONS:
In order for Mrs. X to recover fully, collaborative interventions of other health care professionals are needed. Referral to the physiotherapist for proper mobility and exercise. Referral to the dietician is also needed for proper diet and nutritional value. Also referral to the radiologist for chest x-ray.
Nursing Diagnosis Expected Outcome Nursing Intervention Evaluation
A. Impaired gas exchange Maintain unlabored respirations at 12-20 minutes within four days Assess respirations noting the quality, rate, rhythm, depth, breathing effort and use of accessory muscles. Unlabored pain has been maintained and the patient’s breathing pattern has been normalized.
B. Ineffective breathing pattern Patient maintains normal breathing pattern effectively with the normal range within two days. Auscultation of breath sounds every 2hrs Patient’s respiratory rate remains within established limits
C. In effective airway clearance Maintain normal respiratory rate and clear breath sounds within three days Position client for easy breathing i.e. elevate head of the bed to a semi-fowler’s position and reposition at least every 2hrs. Clear breath sounds has been produced and the normal respiratory rate has been maintained.
D. Activity intolerance Patient is able to perform basic activities without excessive exhaustion or loss of energy and absence of shortness of breath within one week. Assess the patient’s level of physical activity and mobility and assess the need for ambulation aids: bracing, care, and walker. Patient is able to ambulate to the room door and back to the bed without any abnormal changes in vital signs.
E. Disturb sleep pattern Restore proper sleeping pattern within four days. Assess patient’s sleep pattern and changes and frequency by means of observation of the patient while sleeping and awakening. After a few days of nursing intervention the patient is able to display improvement in sleeping pattern as evidenced by: the patient’s ability to go to sleep without being easily awakened and the presence of eye bags have been minimized or have gone.
F. Hyperthermia Maintain normal vital signs especially normal temperature rate within 24hrs. Monitor temperature every 2hrs and monitor signs of dehydration. Patient’s normal temperature rate has been maintained and also other vital signs.
G. Acute pain The patient will be able to mobilize within 48hrs after taking pain relieve medications as ordered. Assess the patient’s pain level every 2hrs while patient is awake until patient’s pain rating is less than 4 on 1-10 scale. Patient is able to mobilize independently
H. Dressing self-care deficit The patient will be able to demonstrate increased ability to dress/groom within three days. Provide dressing aids as necessary and lay clothes out in order which they will be needed to dress. Mrs. X has dressed/groomed herself independently.
I. Bathing self-care deficit Maintain normal respiratory rate and clear breath sounds within three days Assess the ability to perform bathing independently and encourage the family to be involved in caring and monitoring the client and instruct patient to select bath time when he or she is rested and unhurried. Mrs. X is able to bath herself without needing an assistant.
J. Toileting self-care deficit Patient is able to perform basic activities without excessive exhaustion or loss of energy and absence of shortness of breath within one week. Assist in offering bedpan or place patient on toilet every one-one an half hours during day and three times during night. Mrs. X is able to go to the toilet by herself.
No. of words: 1798 words
REFERENCE:
Crisp. J., & Taylor. C. (2005). Fundamentals of nursing (2nd e.d.).
Marrickville, NSW, Australia: Elsevier.
Gulanick. M., & Myers.J.L. (2004). Nursing care plans (8th e.d.).
Philadelphia, USA: Elsevier.
Mariner.A. (1979). The nursing process. (2nd e.d.). St. Louis,
Missouri, USA: Morsby Company.
Nursing process, diagnosis, and care plan. Retrieved April 14, 2016,
From http://www.nursingprocess+diagnosis+careplan.