Nursing Process
Introduction
Nursing process is the fundamental blue print of how to care for the clients. “The nursing process is a standard of practice, which, when followed correctly, protects nurses against legal problems related to nursing care”. (Potter & Perry & Stocket & Hall: 2009). There are five major steps involved in the nursing process which a nursing student must learn. These are assessment, diagnosis, planning, implementation and evaluation. During assessment, the nurse systematically collects, verifies, analyses and communicates data about a client. The purpose of the assessment is to know about a client’s needs, its health problems and how the client responses to the problems some related experiences, goals, lifestyles, values, the health practices and some of the expectations of the health care system. Moreover, a nursing diagnosis “is a statement that describes the client’s actual or potential responses to a health problem, obtained from the assessment database, a review of pertinent literature, the clients past medical records and consultation with other professionals”. (Crip & Taylor & Potter & Perry: 2009). To add on, “Planning is a category of nursing behaviors in which client-centered goals and expected outcomes are established and nursing interventions are selected to achieve the goals and outcomes of care”. (Crip & Taylor & Potter & Perry: 2009). While planning the priorities are set. Moving on, implementation follows after the planning process. It ensures that a safe, efficient and effective nursing care is taking place. Finally, evaluation is the final step of the nursing process that “measures the client’s responses to nursing actions and the client’s progress towards achieving goals”. (Crip & Taylor & Potter & Perry: 2009). This case scenario discuss about Mrs.X who presents to the GOPD with the following health assessments.
Assessment
Subjective Data
1. Bio-data
Name: Mrs.X
Age: 40 years
Sex: Female
Religion: Muslim
Ethnicity: Fijian
Occupation: School Teacher
Marital Status: Married
Address: Damanu Street
Emergency Contact: 9735973
2. Chief Complaint
Cough with headache for the past 3 weeks.
3. History of Present Illness
Had productive cough for the past 3 weeks till today.
The sputum is thick
Also the sputum is yellow in colour
4. Past Medical History
Had similar episode of cough and headache a year ago and was treated.
5. Family Medical History
Has asthma
Has diabetes
6. Social Medical History
Drinks grog occasionally
Smokes 3 rolls of cigarette in a day
Stays in a nuclear family
7. Medication and Allergies
Had been using herbal medication and takes steam inhalation.
Is not allergic to anything.
8. Functional Health Patterns
Needs aunt’s assistance for elimination and personal hygiene daily.
Elimination
Stool output has been normal
Urine output is in fewer amounts due to the patient losing water due to sweat from fever.
Nutritional
Has been having a normal and proper diet.
Objective Data
The patient looks pale and tired
The patient had been sweating due to fever.
Outfits such as cardigans, pompoms and long pants were worn by the patient as she was feeling cold because of her sickness.
The client was also carrying a hand towel due to frequent coughing.
The patients vital were taken. The patient had high temperature.
There was also a rise in the patients pulse rate and had quick respiration due to coughing.
She had a rise in blood pressure which indicates that the objective data is correct.
Diagnosis
1. Impaired Gas Exchange
2. Ineffective Airway Clearance
3. Risk For Suffocation
4. Ineffective Breathing Pattern
5. Risk For Infection
6. Hyperthermia
7. Disturbed Sleep Pattern
8. Activity Intolerance
9. Impaired Comfort
10. Acute Pain
11. Impaired Social Interaction
Planning
1. Maintain the patients’ optimal gas exchange. (Long term goal)
Maintain the patients’ pattern of respiration. (short term goal)
2. To maintain the airway patency and clear breath sounds. (Short term goal)
Maintain normal breathing. (long term goal)
3. To maintain the patients normal sleep pattern. (Short term goal)
To reduce smoking in patient to maintain a clear way for air to move into the body. (long term goal)
4. To maintain the normal rate and depth of respiration. (Long term goal)
5. Patient to remain free from symptoms of infection. (Short term goal)
Patient to carry out appropriate hygiene measures. (Long term goal)
6. Normal body temperature of the patient to be maintained. (Short term goal)
Restore the normal pulse rate and the respiration of the client. (Long term goal)
7. Patient to be able to verbalize understanding of sleep disturbance. (Short term goal)
To improve the patients sleep. (Long term goal)
8. Assist the patient to be able to perform activities of daily living without a change in vital signs and dizziness. (Long term goal)
9. Maintain the patients stated level of comfort. (Short term goal)
10. Decrease the pain level in the patient. (Short term goal)
11. Help patient to be able to socially and opening interact. (Long term goal)
Implementation
1. Monitor the vital signs of the client.
Position the patient with head of bed elevated to an angle of 45 degrees. To promote lung expansion.
Provide patient with rest.
2. Position the patient in semi- fowlers’ position.
Assist patient in taking deep breathes.
The patient would be referred to the doctor for any abnormal changes.
3. Educate the patient about the bed effects of smoking.
Provide patient with oxygen
Position the client in semi-fowlers position
Provide a well-ventilated room with comfort.
4. Place the client in a more suitable and comfortable position and change the position every 2 hours.
Monitor vital signs
Assist the client in taking deep breathes and provide nebulizer if needed
5. Monitor vital signs of patient every 4 hours. Observe temperature rate.
Assist the client to take fluid frequently
6. Assess the signs and symptoms of hyperthermia
Promote rest for patients
Encourage a well-balanced diet.
Maintain fluid intake frequently
Consult doctor if temperature remains higher than 38.5 degree Celsius
7. Advice patient to rest
Recommend patient to limit consuming grog and reduce smoking
8. Minimize environmental activity and noise
Assist client with self-care activities
Limit the number of visitors and their length of stay
Provide a warm, soft and comfortable bed for sleeping
9. Reposition patient every hour
Educate client to use relaxation techniques
Provide a well-ventilated room
Reduce noise level by informing others
Limit the number of visitors and their length of stay.
10. Assess the client’s pain
Monitor vital signs
Advice breathing exercises
Teach client about the divertional activities
11. Teach the client on being interactive with others
Teach clients on the use of verbals and non verbals
Evaluation
1. The patient was able to breathe effectively.
The patient was able to have a normal respiration
2. The patient was able to maintain airway patency and clear breath sounds was heard
Also the patient’s normal breathing pattern was maintained
3. The patient was able to have a normal sleep pattern
The patient had decided to slowly quit smoking as she had realized that it was affecting her health.
4. The normal breathing pattern of patient was achieved
5. Patient was able to perform proper hygiene for herself
The infection was treated before it caused any further problems
6. The normal body temperature was maintained
The pulse rate and respiration was normalized
7. Patient was able to understand about sleep disturbance
Patient was able to improve sleep patterns
8. The client became self- reliant and was able to perform activities of daily living by herself
9. The patient stated level of comfort was achieved and maintained.
10. The patient’s pain level was decreased
The patient felt more comfortable
11. After the assessment the patient was able to openly socialize with the others.
Nursing Diagnosis Planning Implementation Evaluation
Impaired Gas
Exchange Maintain the patient’s optimal gas exchange.
Maintain the patients pattern of respiration
Monitor the vital signs of the client.
Position the patient with head of bed elevated to an angle of 45 degrees. To promote better lung expansion.
Provide patient with rest The patient was able to breathe effectively.
The patient was able to have a normal respiration.
Ineffective airway clearance To maintain the airway patency and clear breath sounds.
Maintain normal breathing. Position the patient in semi-fowlers position.
Assist patient in taking deep breathes.
The patient would be referred to the doctor for any abnormal changes. The client was able to maintain airway patency and clear breath sounds was heard.
Also the patient’s normal breathing pattern was maintained.
Risk for suffocation To maintain the patients normal sleep pattern.
to reduce smoking in patient to maintain a clear way for air to move in. Educate the patient about the about the bad effects of smoking.
Provide patient with oxygen.
Position the client in semi-fowlers position.
Provide a well-ventilated room. The patient was able to have a normal sleep pattern.
The patient had decided to slowly quit smoking as she had realized that it was affecting her health.
Ineffective Breathing Pattern To maintain the normal rate and depth of respiration. Place the client in a more suitable and comfortable position and change position every 2 hours.
monitor vitals
Assist client in taking deep breathes and provide nebulizer if needed. The normal breathing pattern was achieved.
Risk For Infection Patient to remain free from symptoms of infection.
Patient to carry out appropriate hygiene measures. Monitor vital signs of patient every 4 hours.Observe temperature.
Assist client in taking fluid frequently Patient was able to perform proper hygiene for herself.
The infection was treated before it caused any further problems.
Hyperthermia Normal body temperature of the patient to be maintained.
Restore the normal pulse rate and the respiration of the client. Assess the signs and symptoms of hyperthermia.
Promote rest for patients.
Encourage a well-balanced diet.
Maintain fluid intake frequently.
Consult doctor if temperature remains higher than 38.5 degrees Celsius. The normal BODY temperature was maintained.
The pulse rate and respiration was normalized.
Disturbed Sleep Pattern Patient to be able to verbalize understanding of sleep disturbance.
To improve the patients sleep
Patient to be able to rest.
Recommend patient to limit consuming grog and reduce smoking.
Patient was able to understand about sleep disturbance.
Patient was able to improve sleep patterns.
Activity Intolerance Assist the client to be able to perform activities of daily living without a change in vital signs and dizziness. Minimize environmental activity and noise.
Assist client with self-care activities.
Limit the number of visitor’s ant their length of stay.
Provide a warm soft and comfortable bed for sleeping.
The client became self- reliant and was able to perform activities of daily living by herself.
Impaired Comfort Maintain the patient stated level of comfort. Reposition patient every hour.
Educate patient to use relaxation techniques.
Provide a well-ventilated room.
Reduce noise level by informing others.
Limit the number of visitors and their length of stay.
The patient stated level of comfort was achieved and maintained.
Acute Pain Decrease the pain level in patient. Assess the client’s pain.
Monitor vital signs
Advice breathing exercises
Teach client about the divertional activities. The patient pain level was decreased.
The patient felt more comfortable.
Impaired Social Interaction Help patient be able to socially and openly interact Teach the client on being interactive with others.
Teach client on the use of verbals and non verbals After the assessment the patient was able to openly socialize with the others.
Independent Intervention
If cough becomes severe the patient was assisted by giving oxygen and nebulizer.
Semi-fowlers and fowlers positions were used to position the client in order to relieve cough.
Exercises such as inhaling deeply and coughing with open mouth to spit out sputum were done.
Patient was given extra blankets for warmth upon being requested.
Collaborative Intervention
The patient would be referred to the radiologist for X-ray.
She would also be referred to the dietitian for a proper nutritious diet.
Reference
Ackley, B.J. & Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An evidence planning care.
(10th ed.). St. Louis, MO: Mosby Elsevier.
Crisp,J. & Taylor, C., & Potter, P.A., & Perry,A.G.(2009). Fundamentals of Nursing. (3rd ed.).
Chatswood, NSW, Australia.
Ignatavicius, D.D. & Workman, M.L. (2013). Medical Surgical Nursing: Patient centered
Collaborative care. (7th ed.). Vol.1. St. Louis, MO: Saunders Elsevier.
Jarvis, C. (2004). Physical Examination & Health Assessment. (4th ed.). St. Louis, Missouri:
Saunders.
Marriner, A., (1979). The Nursing Process, (2nd ed.). St. Louis, Missouri:Mosby.
Potter,P.A., & Perry, A.G., &Stocket, P.A., & Hall, A.M. (2009). Fundamentals Of Nursing.(8th
ed.). Riverport Lanes; Elvesier.
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