Introduction
Nursing Process is a sequence of organized guideline for nurses to deliver outstanding care. Nursing Process involves five stages which are assessing, diagnosing, planning, implementing and evaluating.
The first step in the nursing process is the nursing assessment. In this stage the nurse gathers information about the patient and documents it. Nurses will carry out patient’s interview (Bio –data), physical examination, document patient’s medical history, enquire patient’s family history and also document on patient’s general appearance (objective data). The second stage is Nursing Diagnosis. In this stage the nurse identifies problems associated with the patient. For one patient there could be many diagnosis. These diagnosis (problems) are also used to see if the patient is at risk of developing any other problem.
The third stage is the planning stage whereby the nurse’s goals are being set. The goals can be long term goals (to be achieved within weeks) or even short term goals (goals to be achieved within hours or few days.). The fourth stage is the nursing intervention. Actions that are done by nurses are assessing and monitoring client and so on. The fifth stage is the evaluation stage. Once all the implementations and actions have taken place the nurse identifies whether the goals were achieved or not. The nurse will see if the patient’s condition has stabilized or not.
This assignment is about a patient that comes to the hospital presenting herself with cough and mild fever for three weeks with yellow and thick sputum. The patient, Mrs X is a married school teacher. Mrs X is assisted by her aunty for elimination and personal hygiene.
Assessment
Bio Data
Name: Mrs X Age: 40 years
Sex: Female Marital Status: Married
Address: Damanu Street Occupation: School Teacher
Chief Complain
What brought you to the hospital today?
Mrs X came to the hospital due to cough for three weeks.
Any other symptoms you notice when you cough?
Mrs X notices her sputum to be thick and yellow in colour.
Is there any other problem happening to you apart from symptoms that you are having? Any Headache or body ache?
Mrs X starts to have head ache when she coughs for 3 days now and pain worsens when lying in supine position.
Is there anything that makes the symptoms better?
The cough is relieved when in fowler’s position.
Did you suffer from the symptom before?
Mrs X had a similar experience of head ache and cough around this time last year.
Because of the symptom are you able to do some work?
Mrs X daily activities are affected; she is unable to cook and is usually assisted by her aunty for elimination and personal hygiene.
Family History
Is there any other disease or condition?
Mrs X also has a family history of Asthma and Diabetes
Social History
Mrs X smokes 3 rolls of cigarettes a day and drinks grog occasionally.
Medical History
Are you treating yourself with any other medication?
Mrs X was treating her cough with herbal medicine but it has worsen.
Objective Data
General Appearance
Mrs X appears to be lethargic due to lack of sleep.
Mrs X appears to be tired due to productive cough.
When Mrs X coughs she seems to be in pain when she coughs
Vital Signs
Temperature: 38.2
Pulse: 85 beats/min
Respiration: 25
Blood Pressure: 150/90
Nursing Diagnosis
1. Impaired Gas Exchange
2. Ineffective airway clearance
3. Ineffective breathing pattern
4. Risk for infection related to diabetes
5. Activity Intolerance
6. Hyperthermia
7. Disturbed Sleep Pattern.
8. Toileting Self-care deficit
9. Impaired Physical mobility
Expected Outcome
1. To maintain a normal gas exchange and to remain free from signs and symptoms of impaired gas exchange.
2. To restore normal breaths sounds and remain free of signs and symptoms of dyspnoea.
3. To maintain a normal breathing pattern.
4. To remain free from signs and symptoms of infections
5. To restore ability to perform daily activities.
6. To maintain a normal body temperature.
7. To restore a normal sleep pattern.
8. To demonstrate improved ability to toilet self-care.
9. To maintain maximum physical ability.
Nursing Intervention
1. – Assess Mrs X for any signs or symptoms of impaired gas exchange such as restlessness, irritability, tachypnoea, dyspnoea and so on.
– Assist Mrs X in breathing by providing breathing devices like the oxygen mask.
– Discourage Mrs X from smoking.
2. Assess for any signs and symptoms of ineffective airway clearance like rapid shallow respirations, dyspnoea and cough.
– Position Mrs X to Fowlers Position to minimise pain when coughing and better breathing.
– Encourage Mrs X to perform deep breathing exercises.
3. Assess for signs and symptoms of ineffective breathing pattern such as dyspnoea, tachypnoea etc.
– Assist Mrs X in breathing by providing breathing devices
– Encourage Mrs X to perform breathing exercises.
4. Provide diet that is low in sugar and starch and more of fruits and vegetables and drink lots of water.
5. – Encourage client to rest to conserve energy.
-Mrs X to be referred to the radiologist (X-ray) and to the physiotherapist.
6. – Give Mrs X tepid sponge bath
– Provide Mrs X with a lot of fluids like water and soup to avoid dehydration.
7. Promote Comfort and Proper ventilation to promote sleep for Mrs X.
– Mrs X to be positioned to Fowler’s position to minimize pain when coughing.
– Allow maximum rest in between treatment.
8. Assist Mrs X with elimination by providing Bedpan or by taking her to the toilet.
9. Mrs X is to be referred to the physiotherapist and to the radiologist for examination.
-Mrs X is to at least perform passive exercise e.g. slight ankle rotation to allow circulation of blood.
Evaluation
1. Mrs X maintained a normal gas exchange through the help of breathing devices.
2. Mrs X remained free of signs and symptoms of ineffective airway clearance by performing deep breathing exercises and her pain was minimized by positioning her to fowler’s position.
3. Mrs X maintained a normal breathing pattern through the help of breathing exercise and breathing devices.
4. Infections were prevented by following preventative measure whereby Mrs X was provided a diet with low sugar and starch level.
5. Mrs X had sufficient rest thus conserved enough energy and is able to perform activities like walking, standing etc.
6. Mrs X’s body temperature was maintained by tepid sponge bath and providing her with a lot of fluid like water.
7. Mrs X was able to maintain a normal sleep pattern by providing a well-ventilated and comfortable environment.
8. Mrs X is able to take care of her own self. She is able to take herself to the toilet and also take care of her own personal hygiene.
9. Mrs X is able to restore her physical ability like walking, bathing etc.
NURSING DIAGNOSIS EXPECTED
OUTCOME NURSING
INTERVENTION EVALUATION
1.Impaired Gas Exchange Long Term Goal
1.To maintain a normal gas exchange and to remain free from signs and symptoms of impaired gas exchange – Assess Mrs X for any signs or symptoms of impaired gas exchange such as restlessness, irritability, tachypnoea, dyspnoea and so on.
– Assist Mrs X in breathing by providing breathing devices like the oxygen mask.
– Discourage Mrs X from smoking Mrs X maintained a normal gas exchange through the help of breathing devices.
2.Ineffective airway clearance Short Term Goal
To restore normal breaths sounds and remain free of signs and symptoms of dyspnoea. Assess for any signs and symptoms of ineffective airway clearance like rapid shallow respirations, dyspnoea and cough.
-Position Mrs X to Fowlers Position to minimise pain when coughing and better breathing.
-Encourage Mrs X to perform deep breathing exercises Mrs X remained free of signs and symptoms of ineffective airway clearance by performing deep breathing exercises and her pain was minimized by positioning her to fowler’s position.
Ineffective breathing pattern Long Term Goal
To maintain a normal breathing pattern Assess for signs and symptoms of ineffective breathing pattern such as dyspnoea, tachypnoea etc.
Assist Mrs X in breathing by providing breathing devices
Encourage Mrs X to perform breathing exercises. Mrs X maintained a normal breathing pattern through the help of breathing exercise and breathing devices.
Risk for infection related to diabetes Short term goal
To remain free from signs and symptoms of infections Provide diet that is low in sugar and starch and more of fruits and vegetables and drink lots of water. Infections were prevented by following preventative measure whereby Mrs X was provided a diet with low sugar and starch level.
Activity Intolerance Short Term Goal
To restore ability to perform daily activities. Encourage client to rest to conserve energy.
-Mrs X to be referred to the radiologist (X-ray) and to the physiotherapist. Mrs X had sufficient rest thus conserved enough energy and is able to perform activities like walking, standing etc.
Hyperthermia Short Term Goal
To maintain a normal body temperature Give Mrs X tepid sponge bath
Provide Mrs X with a lot of fluids like water and soup to avoid dehydration. Mrs X’s body temperature was maintained by tepid sponge bath and providing her with a lot of fluid like water.
Disturbed Sleep Pattern. Short Term Goal
To restore a normal sleep pattern Promote Comfort and Proper ventilation to promote sleep for Mrs X.
Mrs X to be positioned to Fowler’s position to minimize pain when coughing.
Allow maximum rest in between treatment. Mrs X was able to maintain a normal sleep pattern by providing a well-ventilated and comfortable environment.
Toileting Self-care deficit Short Term Goal
To demonstrate improved ability to toilet self-care. Assist Mrs X with elimination by providing Bedpan or by taking her to the toilet. Mrs X is able to take care of her own self. She is able to take herself to the toilet and also take care of her own personal hygiene.
Impaired Physical mobility Short Term Goal
To maintain maximum physical ability. To maintain maximum physical ability Mrs X is able to restore her physical ability like walking, bathing etc.
Independent Intervention
– Assessing Mrs X’s vital signs.
– Assisting Mrs X with elimination that is bedpan and also personal hygiene
– Positioning Mrs X to fowler’s position
– Providing Breathing devices
– Counselling and teaching Mrs X and her family about her condition and how to take care of Mrs X.
Collaborative Intervention
– Referring Mrs X to the Physiotherapy
– Referring Mrs X to the Dietician for her proper diet
– Referring Mrs X to the Radiologist to examine if there is any internal injury.
– Requiring assistance of family members in taking care of Mrs X.
Reference
1. Chilman, M. A & Thomas, M. (1987). Understanding Nursing Care (3rd Ed).
New York: Churchill Living Stone
2. Doenges, E. M., Moorhouse, F.M. & Murr, C.A. (2010), Nursing Care Plans:
Individualizing client care across the life span (9th Ed), Philadelphia,
US: F.A. Davis.
3. Gulonick, M. & Myers, L.J, (2014). Nursing Care Plans: Diagnosis:
Interventions and outcomes (8th Ed). Philadelphia: Elsevier
4. Hogston, R& Marjoram, A. B. (2007), Foundations of Nursing Practise:
Leading the way (3rd Ed), United Kingdom: Palgrave McMillian
5. Lynn, P. (2015), Taylor’s Clinical Nursing Skills: A nursing process approach:
Philadelphia: Wolters Kluwer.