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Nursing Care Plan

Nursing 6064: Medical Surgical Nursing

Submitted to: Tina Garde 1

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Nursing is becoming recognized as a separate discipline and an art, that encompasses the combination of technique, sensitivity and technical knowledge. This is exemplified in the whole nursing process itself. Dier (as cited in Carpenito-Moyet, 2004) states that nursing requires an intricate way of thinking that proceeds from principles to practice, from understanding to acting, from judgement to contact and from reflection to diagnosis. Theory is a required foundation for practice and observations are analyzed to form acceptable diagnoses. Yet, as the practice and dynamics of nursing is still developing itself, the creation of nursing care plans served as a huge breakthrough in creating a systematic evidence-based body of knowledge to direct nursing care. For nurses and healthcare professionals in general, it is an invaluable source of information regarding the patients needs and goals. It is a detailed set of instructions 2006). This case study will demostrate the nursing process from assessment to evaluation by using the format of a traditional nursing care plan. It will be individualized to suit the situation and holistic health status of my client, Mr. Steve Daniels (name changed for privacy). I will use Mason Duries Te Whare Tapa Wha model to assess my clients holistic health status and proceed with the nursing care plan where I will identify his three main problems. Each of the said problems will consist of one goal, three interventions with rationale and finally an evaluation of the success of the executed interventions. The Te Whare Tapa Wha is a Maori health assessment framework which proposes that the spiritual health(Taha Wairua), mental health (Taha Hinengaro) and family health (Taha whanau) are just as important as the physical symptoms of illness (Ministry of Health [MOH], 2008). and suggestions for improving care and avoiding potential complications (Lippincott Williams and Wilkins [LWW],

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CLIENT ASSESSMENT: TAHA TINANA: Mr. Steve Daniels is a 66 year old kiwi with a height of 182 centimeters and weighs 198 pounds who got an acute admission in Taupo Hospital Emergency department due to an exacerbated attack of Chronic Obstructive Pulmonary Disease (COPD) specifically Emphysema. Porth (2005) defines Emphysema as the deterioration of lung resilience and atypical enlargement of airspaces associated with the obliteration of alveolar surfaces leading to lung inflation. Mr. Daniels states that he has had emphysema for eighteen months and struggles with shortness of breath on exertion (SOBOE) everyday. He deals with it by calming himself down and waiting for it to pass but had a particularly severe episode this July 31st which is why he got admitted. His vital signs upon admission are as follows: temperature: 36 degrees celsius, blood pressure: 108/62, heart rate: 92 beats per minute (BPM), O2 saturation: 95% on 2 liter Oxygen prongs and respiration rate: 18 respirations per minute (RPM). His diet consisted of meat, potatoes and green, leafy vegetables and he does not exercise much but had once participated in a strenuous exercise program upon encouragement of the physiotherapist. He recounted that the day after the exercises he was able to mow the lawn but on the second day, his symptoms came back worse than before. He can tolerate 2 minutes of unassisted activity and often needs a stool to take a shower and do most of his daily activities as he could not stand for an extended period of time. He rarely drinks (once a year) but has been a chronic smoker who still smokes until present consuming an average of 10 sticks a day. He tried using nicotine patches but it did not work for him and he was offered smoking
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cessation support which he refused. Shortly after hearing these, I suggested that he add more protein to his diet because it helps promote healing the inflammation in his lungs (Springhouse, 2002). I also taught him diaphragmatic, pursed lip breathing and gradually encouraged him to walk around the ward which he happily did everyday for the rest of his stay. His medications consist of the following: Augmentin and

Roxythromycin are both antibiotics. The former is a prophylactic antibiotic that prevents the development of drug-resistant bacteria and infection (Augmentin, 2010). The latter is used to manage and protect against streptococcal, staphylococcal and many other infections of bacterial origin (Roxythromycin, 2009). For bronchodilators, he takes Atrovent and Salbutamol to manage his shortness of breath (SOB) and wheezing. Atrovent works by relaxing and thus opening the airways (American Association for Respiratory Care [AARC], 2011). Salbutamol on the other hand prevents and treats bronchospasm present in COPD (Datapharm, 2011). He takes Doxazosin to aid him with his enlarged prostate (Medimedia, 2011). Symbicort produces anti-inflammatory effects on the symptoms caused by COPD (AstraZeneca, 2010) and lastly, Prednisone, a corticosteroid that helps lessen problems with bronchoconstriction (LWW, 2009).He has not shown any adverse reactions to these drugs. He has had a history of surgery due to a punctured bowel and a medical history of hypertension. He has no known allergies and his family history is not contributory to his condition. He has no known family history of any respiratory disorder, cardiac disorder or Diabetes. For symptoms he exhibits shortness of breath, productive cough (thick yellow sputum) and barrel chest. The multidisciplinary team involved in his care are the dietician, respiratory nurse and physiotherapist.
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TAHA HINENGARO Mr. Daniels is alert, orientated to time and place, communicates coherently and is able to follow instructions. He scored 15 in the Glasgow Coma Scale . Patients can get a maximum of 15 with the lowest score being 3. Those who score in the range of 3-8 are usually considered to be in a comatose state (Rowlett, 2001). He considers himself as a laidback and optimistic person. In his own words: worrying wont change anything 2011). (S. Daniels, personal communication, August 1, He has a generally calm

temperament but admits that he could sometimes be impatient when has a bad SOB episode. Sometimes his frequent fits of SOB affects him as well because it makes him anxious. I assured him that it is normal to have those feelings when youre struggling to breath but that he could to learn to manage it well. He believes in not giving up and to keep moving forward no matter what happens. He loves to socialize but when his condition does not allow him, he entertains himself by gardening, reading and playing sudoku. TAHA WAIRUA Mr. Daniels is a Roman Catholic but rarely goes to church because he believes that faith is more than just the religious traditions and he believes in a Supreme Being that governs everything although not necessarily the God of Catholics. He loves nature and since he lives close to Mount Tauhara, he enjoys looking at it describing it as a relaxing activity together with gardening. TAHA WHANAU The clients family consists of his wife and his sister. His wife visits every night from 5:30 until 7:00 pm and they appear to share a very intimate relationship with each other. They are seen always talking during visiting hours and his wife always brings food to him at least twice a day. They live in their own house close to the
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Tauhara mountain range while his sister is down in Palmerston North. He states that although they are far away, they keep in touch through the phone and that she goes to visit him every few months.

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Nursing Care Plan

NURSING DIAGNOSIS

GOAL

Nursing Rationale Interventions

a)Monitor vital signs a)Monitoring vital sign deviations like respiratory crisis, increased heart rate, blood pressure and adventitious lung or heart sounds can help detect and avoid pulmonary or cardiovascular complications early (Wilkinson & Ahern, 2009).

EVALUATION

1) Impaired gas exchange related to alveolarcapillary membrane changes secondary to recurrent inflammation as evidenced by Oxygen saturation levels ranging from 88- 89%.

Patient will be able to improve oxygen perfusion by maintaining oxygen saturation levels of 92% or higher on air within 24 hours.

Client was able to increase his oxygen saturation levels from 89% to 91-92% and was able to maintain it on air within the 24 hour time limit.

b)Administer low flow oxygen (2 liters or less) via nasal cannula.

b) Maintaining low oxygen levels prevent the risk of oxygeninduced respiratory depression (Wilkinson & Ahern, 2009). Oxygen administration with the use of nasal cannula is preferred to lessen the clients

2009000414 feelings of suffocation (Moyet-Carpenito, 2004).

c) Administer corticosteroids (Prednisone) as prescribed.

c) Corticosteroids like Prednisone deter prostaglandin, eosinophil and other inflammatory mediator generation thus lessening bronchoconstriction (LWW, 2009).

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NURSING DIAGNOSIS
2) Activity intolerance related to fatigue secondary to chronic tissue hypoxia.

GOAL
Client will be able to demonstrate improved activity tolerance by mobilizing with assistance around the ward for at least 5 minutes or more within 3 days.

Nursing Rationale Interventions

a) Assess for abnormal responses to increased activity (pulse rate and respiratory rate). a) Lack of tolerance to activity can be appraised by assessing cardiac, circulatory level and respiratory status (CarpenitoMoyet, 2004).

EVALUATION
After 3 days of gradual exercise, client was able to ambulate assisted with a walker around the ward for 13 minutes in a steady gait.

b)Encourage daily activity with rests in between.

b) Physical activity with rest intervals aid in avoiding fatigue and preserving energy (LWW, 2003). Continued intermediate shortness of breath caused by supervised exercise increases accessory muscle stamina and respiratory capacity (Carpenito-Moyet, 2004).

c) Gradually increase clients daily activities as tolerance increases.

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NURSING DIAGNOSIS

GOAL

Nursing Rationale Interventions

EVALUATION

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2009000414 3) High risk for ineffective therapeutic routine management related to lack of knowledge about condition, treatments and breathing exercises as manifested by inability to practice breathing exercises during attacks and inability to prevent symptoms. Client will be able to manage his condition more effectively by demonstrating proper breathing techniques, verbalizing and/or practicing what he learned within 3 days. a)Teach and have client demonstrate breathing exercises like pursed lip and diaphragmatic breathing. a)Pursed lip breathing extends expiration time therefore avoiding bronchiolar failure and air trapping.(p. 703) Abdominal breathing concentrates on the utilization of the diaphragm muscles in lieu of the accessory muscles to reach maximum inspiration and slow the respiratory rate (Brown & Edwards, 2008). b) Cold weather stimulates bronchospasm which then leads to shortness of breath (Springhouse, 2002). Client was able to enumerate measures to manage his condition and was also able to demonstrate pursed lip breathing and abdominal breathing within the time limit specified.

b) Teach client to avoid going out during cold weather.

c) Encourage client to increase protein intake and decrease carbohydrate intake in their diet.

c) Protein promotes healing of the inflamed airways (Springhouse, 2002). Carbohydrates increase carbon dioxide concentration in the blood which is

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2009000414 not good for people with carbon dioxide retention like clients with COPD (CarpenitoMoyet, 2004).

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References American Association for Respiratory Care. (2011). Medication: Ipratropium Bromide. Retrieved August 8, 2011, from http://www.yourlunghealth.org/medication/desc/ipratropium/ AstraZeneca. (2010, December 22). Symbicort and COPD: Mechanism of action. Retrieved August 8, 2011, from http://copd.symbicort.com/mechanism-of-action/ Augmentin. (2010, November 8). Retrieved August 8, 2011, from Rxlist: The internet drug index: http://www.rxlist.com/augmentin-drug.htm Brown, D., & Edwards, H. (2008). Lewiss medical-surgical nursing. Assessment and management of clinical problems. (2nd ed.). Sydney: Elsevier. Carpenito-Moyet, L. J. (2004). Nursing care plans and documentation (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Datapharm. (2011). Salbutamol. Retrieved August 8, 2011, from http://www.nhs.uk/medicine-guides/pages/MedicineOverview.aspx? condition=Bronchospasm&medicine=salbutamol Lippincott Williams & Wilkins. (2003). Handbook of geriatric nursing care (2nd ed.). Philadelphia: Author. Lippincott Williams and Wilkins. (2006). Charting made incredibly easy (3rd ed.). Philadelphia: Author. Lippincott Williams & Wilkins. (2009). Nursing pharmacology made incredibly easy (2nd ed.). Philadelphia: Author. Medimedia. (2011). Mims. Auckland: Author.

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Ministry of Health. (2008). Te whare tapa wha- Maori health model. Retrieved August 8, 2011, from http://www.maorihealth.govt.nz/moh.nsf/pagesma/445 Rowlett, R. (2001). Glasgow Coma Scale. Retrieved 8 2011, August, from http://www.unc.edu/~rowlett/units/scales/glasgow.htm Roxythromycin. (2009). Retrieved August 8, 2011, from http://www.webhealthcentre.com/drugix/Roxythromycin_di0124.as px Springhouse. (2002). Patient teaching reference manual. Philadelphia: Lippincott Williams & Wilkins. Wilkinson, J. M., & Ahern, N. R. (2009). Prentice hall nursing diagnosis handbook (9th ed.). Philippines: Pearson Education South Asia .

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