Introduction
Nursing process is a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. These processes and assessment (data collection), nursing diagnosing, planning, implementation and evaluation, with subsequent modifications used as feedback mechanisms to promote the resolution of the nursing diagnosis. The process as a whole is cyclical, with the steps being interrelated, interdependent, and recurrent. (Williams & Wilkins, 2014). This essay focuses on a case scenario based on Mrs.X who came in to the hospital with a chief complaint of cough for last three weeks.
Furthermore, this essay will discuss on patients subjective data, objective data, nursing diagnosis, expected outcomes, nursing interventions, implementation, evaluation, independent interventions, dependent interventions and collaborative.
Steps in nursing process:
Assessment- systematic collection of data to determine the patient’s health status and to identify any actual or potential health problems. (Williams & Wilkins, 2014). It is the process of collecting data, organizing data, validating data and documenting data. (Kozier & Erb’s, 2008).
Nursing diagnosis- identification of actual or potential health problems that are amenable to resolution by nursing actions. (Williams & Wilkins, 2014). It is the process of analyzing data, identifying health problems, risks and strengths, and formulating diagnostic statements. (Kozier & Erb’s, 2008).
Planning- development of goals and a care plan designed to assist the patient in resolving the nursing diagnosis. (Williams & Wilkins, 2014). It is the process of prioritizing problems or diagnosis, formulating goals or desired outcomes, selecting nursing interventions and writing nursing interventions. (Kozier & Erb’s, 2008).
Implementation- actualization of the care plan through nursing interventions or supervision of others to do the same. (Williams & Wilkins, 2014). It is the process of reassessing the patient, determining the nurses need for assistance, implementing the nursing interventions, supervising delegated care, and documenting nursing activities. (Kozier & Erb’s, 2008).
Evaluation- determination of the patient’s responses to the nursing interventions and of the extent to which the goals have been achieved. (Williams & Wilkins, 2014). It is the process of collecting data related to outcomes, comparing data with outcomes, relating nursing actions to patient’s goals or outcomes, drawing conclusions about problem status, and continuing, modifying or terminating the patient’s care plan. (Kozier & Erb’s, 2008).
Assessment
Subjective data:
Bio-data
Name: Mrs. X
Age: 40 years old
Sex: female
Religion: Methodist
Ethnicity: Fijian
Marital status: married
Occupation: school teacher
Address: Damanu Street, Labasa
Emergency contact: 8818691
Chief complain
Mrs.X was brought in by her husband and her two children to the hospital. She was seen in General Outpatient department. She came in with complaint of cough for last three weeks.
History of present illness
According to Mrs.X she mentioned that the cough was very productive for three weeks till today. The cough started when she had mild fever three weeks ago. Mrs.X told that she also noticed that the content of her sputum is yellow in color and thick. The cough worsens even though herbal and steam inhalations are provided. Mrs.X stated that she also started to experience headache when she coughs for the last three days; the pain is sharp, throbbing, and worsens when she lies down. Thus the cough is relieved when she is in a fowler’s position.
Past medical history
Mrs.X was once brought in to the Labasa hospital due to similar episode of cough and headache a year ago and was treated.
Family medical history
Mrs.X is living in a nuclear family which consists of her husband and her two children. Mrs.X have a family history of asthma and diabetes.
Social history
Mrs.X drinks grog occasionally and smokes three rolls of cigarette in a day.
Medications and Allergies
Mrs.X takes herbal and steam inhalations but the cough worsens. Mrs.X has no allergies from any food and drugs.
Functional health patterns
• Elimination pattern- Mrs. is assisted in bowel and urinary elimination pattern.
• Activity-(exercise pattern) – activities of her daily living is also been affected as she cannot mobilize around to perform daily household activities such as cooking.
• Sleep and rest pattern- due to productive cough Mrs. cannot sleep and rest properly.
• Nutritional-(metabolic pattern) – Mrs. cannot eat food properly as swallowing of food causes pain to her throat.
Objective data:
General Appearance
Mrs. looked tired and weak. She wore warm clothes in a bright sunny day.
Vital Signs
Temperature: 38.5 Celsius degrees
Blood Pressure: 150/90
Pulse: 88 beats/minute
Respiration: 25
• Moreover, while assessing Mrs. her breathing sound was not normal and her body temperature was high.
Nursing Diagnosis
1. Impaired gas exchange
2. Ineffective airway clearance
3. Ineffective breathing pattern
4. Risk for infection
5. Acute pain
6. Disturbed sleep pattern
7. Hyperthermia
8. Activity intolerance
9. Impaired physical mobility
10. Impaired comfort
Planning
Expected outcome:
1. To maintain a normal gas exchange pattern within 2 weeks.
2. To restore an effective airway clearance as evidenced by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths within a week.
3. To maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea within 2 weeks.
4. Patient to remain free of infection, as evidenced by normal vital signs and clear mucus secretion within 5 days.
5. Patient exhibits increased comfort such as baseline levels for pulse, blood pressure, respirations and relaxed body posture.
6. Patient will be able to maintain optimal amount of sleep, as evidenced by rested appearance within 2-3 days.
7. Patient to maintain body temperature below 39 Celsius degrees.
8. Patient to maintain tolerance during physical activity as evidenced by respiratory rate less than 20 breaths/minute within 3-4 days.
9. Patient to maintain normal mobility pattern without any complications within a week.
10. Patient to maintain reduction of discomfort as evidenced by appropriate rest within 3 days.
Nursing interventions:
1. *Access respirations, noting quality, rate, rhythm, depth and breathing effort.
*Monitor vital signs.
2. *Assist patient in use of respiratory devices and techniques.
3. *Assist patient in use of respiratory devices and techniques.
*Assess the breathing pattern of the patient.
4. *Monitor the color of mucus secretions.
*Encourage patient for coughing and deep breathing.
5. *Assess the characteristics and location of the pain.
*Assess signs and symptoms of pain to relief pain.
6. *Provide a comfortable and quiet environment for patient to have a proper sleep and rest.
7. *Monitor the patient’s body temperature.
*Maintain a cool temperature environment to normalize patient body temperature.
*Encourage patient to take an increased amount of fluid.
8. *Monitor patients physical daily activities.
*Assess patient’s general conditions.
9. *Encourage patient to mobilize at regular intervals.
*Encourage patient to do some form of exercise.
10. *Provide comfort and assist patient in positioning of the body.
Implementation
1.*Instruct client to have shallow breathing pattern if hyperventilating.
*Consult to appropriate health care provider if gas exchange pattern worsens.
2. *Instruct client to take deep breath and cough every 1-2 hours to take out mucus secretions and clear out airway passage.
3. *Practice deep breathing exercise.
*position patient to fowlers position for effective breathing.
4. *Encourage client to wash hands before and after visiting toilet and handling of food.
5. *Assist the patient to turn at regular intervals to relief pain.
6. *Encourage client to follow sleeping timetables.
*Ensure noise free and good ventilated room for the client.
7. *Assist patient with tepid sponge bath.
*Encourage patient to avoid hot, heavy meals.
8. *Assist patient in doing physical activities to help the patient to have normal respiratory functions.
9. *Encourage patient to move freely without any complications.
10. *Ensure that the patient is comfortable.
*Assist patient to find position of comfort.
Evaluation
1. The patient was able to normalize gas exchange pattern after 2 weeks.
2. The patient was able to restore effective airway clearance after 1 week.
3. The patient was able to normalize effective breathing pattern after 2 weeks.
4. The patient was able to get free from infection after 5 days.
5. The patient was able to relief pain after 1 week.
6. The patients sleeping pattern was normalized after 3 days.
7. The patient’s body temperature was normalized after 5 days.
8. The patient was able to carry out normal physical activities after 4 days.
9. The patient was able to mobilize after 1 week without any complications.
10. The patient was able to feel comfortable after 3 days.
Nursing diagnosis Expected outcome Nursing intervention Evaluation
1.Impaired gas exchange To maintain a normal gas exchange pattern within 2 weeks.
*Access respirations, noting quality, rate, rhythm, depth and breathing effort.
*Monitor vital signs.
The patient was able to normalize gas exchange pattern after 2 weeks.
2.Ineffective airway clearance To restore an effective airway clearance as evidenced by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths within a week.
Assist patient in use of respiratory devices and techniques. The patient was able to restore effective airway clearance after 1 week.
3.Ineffective breathing pattern To maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea within 2 weeks.
*Assist patient in use of respiratory devices and techniques.
*Assess the breathing pattern of the patient.
*The patient was able to normalize effective breathing pattern after 2 weeks.
4.Risk for infection *Patient to remain free of infection, as evidenced by normal vital signs and clear mucus secretion within 5 days.
*Monitor the color of mucus secretions.
*Encourage patient for coughing and deep breathing.
*The patient was able to get free from infection after 5 days.
5.Acute pain *Patient exhibits increased comfort such as baseline levels for pulse, blood pressure, respirations and relaxed body posture.
*Assess the characteristics and location of the pain.
*Assess signs and symptoms of pain to relief pain.
*The patient was able to relief pain after 1 week.
6.Disturbed sleep pattern *Patient will be able to maintain optimal amount of sleep, as evidenced by rested appearance within 2-3 days.
*Provide a comfortable and quiet environment for patient to have a proper sleep and rest. *The patients sleeping pattern was normalized after 3 days.
7.Hyperthermia *Patient to maintain body temperature below 39 Celsius degrees.
*Monitor the patient’s body temperature.
*Maintain a cool temperature environment to normalize patient body temperature.
*Encourage patient to take an increased amount of fluid.
*The patient’s body temperature was normalized after 5 days.
8. Activity intolerance *Patient to maintain tolerance during physical activity as evidenced by respiratory rate less than 20 breaths/minute within 3-4 days.
*Monitor patient’s physical daily activities.
*Assess patient’s general conditions.
*The patient was able to carry out normal physical activities after 4 days.
9. Impaired physical mobility *Patient to maintain normal mobility pattern without any complications within a week.
*Encourage patient to mobilize at regular intervals.
*Encourage patient to do some form of exercise.
*The patient was able to mobilize after 1 week without any complications.
10.Impaired comfort *Patient to maintain reduction of discomfort as evidenced by appropriate rest within 3 days.
*Provide comfort and assist patient in positioning of the body.
*The patient was able to feel comfortable after 3 days.
Independent intervention
• Monitor vital signs (temperature, blood pressure, pulse and respiration).
• Personal hygiene of the patient.
• Monitoring the input and output.
• Positioning of the patient.
• Health education- educate client on how to do cough and deep breathing exercise.
Dependent intervention
• Dietician- help in planning the diet intake for the patient.
• Physiotherapist- helps the patient to mobilize freely.
• Doctors- prescribe medication for the patient.
Collaborative
• Dietician- help in planning the diet intake for the patient.
• Physiotherapist- helps the patient to mobilize freely.
• Pharmacist- supplies medication as prescribed by the doctor.
• Laboratory technician- to process with blood test and send the results.
• Family members- help the client after discharge in decision making process such as the type of diet to intake.
Reference
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