NURSING PRACTICE
ASSESSMENT 2
NURSING PROCESS
ASHNEEL GOUNDER
849
Introduction
“Nursing process is an organized systematic method of providing individualized nursing care that focuses upon identifying and treating unique responses of individual or groups to actual or potential alteration in health. Nursing process consists of five steps; assessments, diagnosis, planning, implementation and evaluation.” (Drauna, 2016)
Nursing process is carried out because to know a patient’s health care status, a plan to identify the needs of a patient, to diagnose the health problem so that there is a faster recovery of the patient and to follow a specific guide in order to provide better and efficient care to the patient.
Nursing process is very important for the nurse’s as well as the client’s because nurses are able to provide a holistic care to the patient, nurses are able to work together to provide individualized care to the patient and it also allows the care to carry on as long term and short term goals.
This assessment will carry out a nursing process on the chief complaint which is productive cough. “A productive cough produces mucus (sputum). The mucus may have drained down the back of the throat from the nose or sinuses or may have come up from the lungs. A productive cough should not be suppressed – it clears mucus from the lungs.” (www.m.webmd.com )
Productive cough can be a dangerous health problem as it causes a lot of problem in a person’s health status and also the daily living of a person. It has many signs and symptoms where a person can know that he or she is suffering from productive coughing.
NURSING ASSESSMENTS
SUBJECTIVE DATA
“Subjective data are the information communicated to the nurse by the client, family or community.” (Treas& Wilkinson, 2014)
Bio data
Name: Mrs. X
Age: 40 years old
Sex: Female
Marital status: Married
Address:Damano Street
Chief complaint: Patient is having productive cough for three weeks till today and she noticed that her sputum is yellow in color and thick.
History of present illness:
• Mode of onset: the cough started when she had mild fever three weeks ago.
• Location of pain: experiences head ache when she coughsfor the past three days.
• Character of symptoms:patient experiences sharp and throbbing pain.
• Aggravating symptoms: the symptoms worsen when patient lies down.
• Precipitating factors: the cough is relieved when the patient is in fowlers position.
• Past treatment and evaluation of the symptom: patient has experienced similar episode of cough and headache a year ago.
• Effects of her symptoms on her daily living: the patient cannot mobilize around to perform daily household activities as cooking and seeks assistance in elimination and personal hygiene.
Past medical history:none
Family medical history:asthma and diabetes
Social history: the patient lives with her nuclear family with two children in Damanu Street. The patient occasionally drinks grog and smokes three rolls of cigarette a day
Allergies: nil known
OBJECTIVE DATA
“Objective data are observable and measurable data (signs) obtained through observation, physical examination and laboratory and diagnostic testing.” (www.delmarlearning.com)
General appearance: patient is lethargic and seeks assistance from relative in mobilizing.
Vital signs:
• Temperature
• Pulse
• Blood pressure
• Respiration
• Oxygen saturation
• Capillary blood glucose stat
DIAGNOSIS
1. Ineffective airway clearance
Expected outcome-the patient to maintain effective airway clearance
2. Impaired gas exchange
Expected outcome-the patient to have paired gas exchange
3. Ineffective breathing pattern
Expected outcome- the patient maintain to have effective breathing pattern
4. Risk for suffocation
Expected outcome-the patient to breathe clearly
5. Risk for infection
Expected outcome: the patient to have normal immune status
6. Ineffective thermoregulation
Expected outcome-the patient to have homeostasis in the body and have normal core temperature
7. Disturbed sleeping pattern
Expected outcome- the patient to have self-control sleep
8. Impaired physical mobility
Expected outcome- ambulation, walking, joint movement and active mobility
9. Interrupted family process
Expected outcome- the patient to have family coping, family functioning and normal family status
10. Anxiety
Expected outcome- the patient to become confident and self-control
PLANNING
1. Ineffective airway clearance
• Airway management
• Airway suctioning
2. Impaired gas exchange
• oxygen therapy
• respiratory monitoring
• clients behavior
3. Ineffective breathing pattern
• after 8 hours of nursing intervention the client will establish an effective respiratory pattern
4. Risk for suffocation
• Positioning of the client
5. Risk for infection
• After discharge the patient has to understand the importance of personal hygiene
6. Ineffective thermoregulation
• After 8 hours of nursing intervention the patient will have an optimal level of thermoregulation
7. Disturbed sleeping pattern
• Following a day of nursing intervention the patient will achieve optimal sleep
8. Impaired physical mobility
• After 1-2 weeks of nursing intervention the patient will be able to mobilize without assistance
9. Interrupted family process
• Provide opportunities to the patient to express concern, fears or questions
10. Anxiety
• After the nursing intervention the patient will have less stress and anxiety
Implementation
1. Ineffective airway clearance
Airway management- auscultate breathing sounds
Rationale- presence of crackles during late inspiration indicates fluid in the airway
Airway suctioning-clear secretions by gentle suction of the pharynx
Rationale-gentle suctioning may stimulate coughing and helps remove secretions
2. Impaired gas exchange
Oxygen therapy- monitors oxygen saturation continuously by using a pulse oximeter
Rationale-oxygen saturation of less than 90% indicates significant oxygenation problems
Respiratory monitoring- monitor respiratory rate, depth and effort
Rationale-increased respiratory rate can be a sign of hypoxia
Client’s behavior-monitors client’s mental status for onset of restlessness, agitation, confusion and extreme lethargy
Rationale-changes in behavior and mental status can be early signs of impaired gas exchange
3. Ineffective breathing pattern
After 8 hours of nursing interventions the client will establish an effective respiratory system
– Auscultate chest
– Assess for discomfort
– Encourage position of comfort
Rationale
– To evaluate character of breathing sounds/secretions
– That may restrict/limit respiratory response
– To provide relieve of causative factors
4. Risk for suffocation
Position of the client- elevate the head of the bed to 45 degrees and re position every 2 hours
Rationale- an upright position allows for maximal air exchange and long expansion
5. Risk for infection
After discharge the patient has to understand the importance of personal hygiene
– Demonstrate proper hand washing technique
– Educate the patient on proper diet and hydration
Rationale
– To prevent the spread of infection
– Proper hydration will help the body to excrete of waste products and transportation of oxygen
6. Ineffective thermoregulation
After 8 hours of nursing interventions patient will have a optimal level of thermoregulation
– Monitor temperature four hourly
– Provide extra blankets to the patient at night
– Give medications as charted
Rationale
– To rule out abnormal temperature
– To keep the patient warm
– To maintain the normal range of body temperature
7. Disturbed sleeping pattern
Following a day of nursing intervention the patient will achieve optimal amount of sleep
– Assess the sleep pattern disturbances that are associated with the environment
– Do as much care as possible without waking up the patient and try to more care when the patient is awake
Rationale
– High percentage of sleep disturbances can affect the recovery of the patient
– To avoid sleep disturbances during sleep and rest
8. Impaired physical mobility
After 1-2 weeks of nursing interventions the patient will be able to mobilize without assistance
– Patient is encouraged to mobilize via wheel chair
– Encourage patient to mobilize without assistance after 1 week
Rationale
– For patients safety and minimize falls
– The patient will not rely on the relative
9. Interrupted family process
Provide opportunities to the patient to express concerns, fears or questions
– Assess the family members perception of problem
– Consider cultural factors
– Counsel the family member
Rationale
– Understanding others perceptions can lead to clarification and problem solving
– In some cultures the male makes decisions in regards to health care
– So the family members understand the health problem
10. Anxiety
After the nursing intervention the patient will have less stress and anxiety
– Outline the contributing factors to stress
– Nurse patient in a quite environment
– Limit visitors to the patient
Rationale
– Stress delays recovery of the patient
– Quite environment helps to relax the patients mind
– Bad news from the visitors can increase stress level
Evaluations
DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
1. Ineffective airway clearance – airway management
– airway suctioning – auscultate breathing sounds
– clear secretions by gentle suction of the pharynx – after a day of airway management and suctioning the patient now has clear airway
2. Impaired gas exchange – oxygen therapy
– respiratory monitoring
– clients behavior – monitor oxygen saturation continuously by using oxi meter
– monitor respiratory rate, depth and effort
– monitor clients mental status for onset of restlessness, agitation, confusion and extreme lethargy – after this intervention patient was able to maintain 100% oxygen saturation and there was also a change in patients behavior
3. Ineffective breathing pattern – after 8 hours of nursing intervention the client will establish an effective respiratory pattern – auscultate chest
– assess for discomfort
-encourage position of comfort – Goal met. After 8 hours of nursing intervention the client was able to establish an effective respiratory pattern
4. Risk for suffocation – position of the client – elevate the head of the bed to 45 degrees and reposition client every 2 hours – after this intervention the patient did not have any risk of suffocation
5. Risk for infection – after discharge that the patient will understand the importance of personal hygiene – demonstrate proper handing washing techniques
– educate the patient on proper diet and hydration – after discharge the client was able to demonstrate back the proper hand washing techniques and understand the importance of nutrition and hydration
6. Ineffective thermoregulation – after 8 hours of nursing interventions the patient will have an optimal level of thermoregulation – monitor temperature 4 hourly
– provide extra blankets to the client at night
– give medications as charted – after 8 hours of nursing care the patients temperature was in a normal range
7. Disturbed sleeping pattern – following a day of nursing interventions the patient will achieve optimal amount of sleep – assess sleeping pattern disturbances that are associated with the environment
– do as much care as possible without waking up the client and try to do more care when the client is awake – after a day of nursing intervention the patient was able to display improvements in sleeping patterns
8. Impaired physical mobility -¬ after 1- 2 weeks of nursing interventions the patient will be able to mobilize without assistance – patient is encouraged to mobilize via wheel chair
– encourage patient to mobilize without assistance after 1 week – after 1-2 weeks of intervention the patient was able to mobilize without assistance
9. Interrupted family process – provide opportunities to the patient to express concerns, fears or questions – assess the family members perception of problem
– consider cultural factors
– counsel the family members – after the nursing intervention the family members doubts was cleared and they participated in the decision making as well as working together
10. Anxiety – after the nursing intervention the patient will have less stress and anxiety – outline the factors contributing to stress
– nurse the patient in a quite environment
– limit the visitors to the patient – after the nursing intervention the patient had adequate amount of physical and mental rest
LONG TERM GOALS
After the patient is discharged the same health problems to should not happen again. Patient should be able to mobilize without assistance. Patient should be able to quit smoking. Encourage patient to visit the hospital if there any complications. Patient should be able to understand the complications. Patient should understand the importance of personal hygiene and apply that in their daily activities. Also the patient should understand the importance of medications and that it should be taken on time. Patient is also encouraged to attend clinics. Patient should fully recover before discharge.
SHORT TERM GOALS
After 8 hours of nursing interventions the patient will be able to have some signs of recovery and improvement in mobility. Patient should be able to improve sleeping pattern and there should be absence of restlessness. Family members should learn the signs of hypoxia and airway obstruction. The patient should be educated on personal hygiene and effects of smoking on the body. The family members should be also educated on how to take care of the patient at home. The client should be assisted in deep breathing exercise and perform control coughing as this will help the patient to clear the sputum from the airway. Loneliness, anger, fears and worries to be identified and should be dealt with. Also the family should be assisted in setting realistic goals which will help the family gain control over the situation.
INDEPENDENT INTERVENTIONS
Nurses assess the patient’s condition and formulate interventions which come under nurse’s scope of practice. These interventions are done independently by the nurse and do not seek permission from other health personals, only the patient’s approval is needed. Firstly, vital signs are a very important nursing intervention. It should be taken every four hours and if patient gets stable, then it is taken twice or three times a day. Secondly, it is important to monitor oxygen saturation and suction airway to clear secretions. Thirdly, teach the patient how to perform deep breathing exercise and control coughing at home. Also, educate the family and the patient about the significances of changes in sputum characteristics. Fourthly, consul the patient to stop smoking and highlight impacts of smoking on patient’s health. Finally, provide health education to the patient on medication compliance, risk for infection, proper hand washing and diet.
COLLABORATIVE INTERVENTIONS
Nurses work hand in hand with health workers to make health care more effective. Firstly, the physician documents the daily plans in the patient’s folder which guides the nurses to provide care for the patient. The doctor prescribes medications and gives the stat does to the patient. Nurses administer as per drug chart. Secondly, the dietician. Nurses refer patients to dietician if patients are for special nutritional need. Then, the dietician makes the meal plans for the patient. Thirdly, physio-therapist will advise the patient on mobility and exercise. Fourthly, since the patient is smoking tobacco, the nurse should collaborate with a professional consular which will help the patient to quit smoking and will also may help in solving other problems for the patient such as personal or family problems. Finally, the nurses will work together with laboratory technician for the blood results and specimen results and the nurse also collaborates with the pharmacist in regards to patient’s medicine.
REFERENCE
Coughs, age 12 and older- topic overview. (2014, November): Retrieved from:
http://www.webmd.com/cold-and-flu/tc/coughs-topic-overview
Drauna, U. (2016, April 5th). The Nursing Process. Lecture presented by Fundamentals of Nursing Practice Strand, Sangam College of Nursing, Labasa, Fiji.
Nursing Fundamentals: Caring & Clinical Decision Making. (1945): Retrieved from:
http://www.delmarlearning.com/companions/content/0766838366/students/ch11/faq.asp \
Treas, S, L., & Wilkinson, M, J. (2014). Basic Nursing Concepts, Skills & Reasoning.Philadelphia, USA: F.A Davis.