STRESSORS

The patient’s attitude towards life (Intrapersonal)- He feels depressed, stating “I

don’t know what’s going on with me, but I’m ready for it all to end.”
The patient’s reliance on his wife (Interpersonal)- At one moment he feels he is
able to make important decisions regarding his health by himself. But, then feels
the strong need to consult his wife after to receive her opinion on his decision.
The patient’s residence (Extra Personal)- He and his wife are unsure as to what is
best as far as where to reside; at home (currently) or in a nursing home. One feels
being at home will allow for comfort even though more help is needed; while the
other believes living in a nursing home will allow for 24hour care as well as better
safety precautions.
 Outcome/goal: Patient will expectorate at least 30mL of secretions and maintain
airway patency through end of clinical day.
Nursing Interventions
Assess rate, depth and rhythm
of respirations and chest
movement.
(Independent/Secondary)
Auscultate lung fields.
(Independent/Secondary)
Implement medications such
as: mucolytics, expectorants,
and bronchodilators.
(Dependent/Secondary)
Assess and educate the
patient’s knowledge of: the
disease, its contributing causes,
treatment and preventative
ways.
(Independent/Primary)
Inform and support the
reduction and/or cessation of
smoking by referring to
appropriate support
groups/clinics.
Scientific Evaluation
Rationale
“Assesses for Patient exhibited a respiration rate of 28 with
respiratory distress” irregular rhythm and shallow breathing during
(Ignatavicius & AM vitals (@ 0730).
Workman, 2015, p. Patient was a bit worked up, anxious, depressed,
591). and sleepy.
I would recommend waiting until the patient
was fully awake, as well as after some of his
anxiety/depression was relieved.
“Crackles indicate Auscultation of lung fields yielded rhonchi
fluid in interstitial breath sounds in the right lower lobe and
and alveolar areas; decreased breath sounds with minimal
wheezing indicates wheezing bilaterally in upper lobes.
inflammation or I would recommend making sure the patient is
exudate in airways; sitting upright with head of bed elevated for
bronchial breath accurate assessment findings; as well as to
sounds indicate benefit the patient’s breathing.
areas of density or
consolidation”
(Ignatavicius &
Workman, 2015, p.
591).
“To loosen up the Mucomyst and Proventil given in a nebulizer
mucus in your treatment with student nurse and clinical
lungs” (Woods, professor. Observed the patient throughout the
2010, p. 46). day, expectorating thinned secretions.
I would recommend encouraging more fluids to
remain hydrated with the removal of secretions.
“Regular pulmonary Patient understood the disease and preventative
hygiene and overall ways when stating, “I should always wash my
fitness help hands and maintain adequate physical activity.
maintain maximal And, I need to complete the entire course of the
functioning of the antibiotics to be in the clear.”
respiratory system I would recommend teaching the patient when
and prevent illness” wife was around as well; as she aids in taking
(Ignatavicius & care of him.
Workman, 2015, p.
501).
“Smoke bothers Talked with the patient and he stated, “I know
your lungs and it’s bad for my health, so I guess I can work on
makes it harder for cutting it out.” Asked the primary nurse to
them to fight off include smoking cessation clinics/support in
patient’s discharge plan.
(Collaborative/Tertiary) infections” (Woods, I would recommend, once again, getting the
2010, p. 46). wife involved; to be able to give patient a push
if needed.

Outcome/Goal: Patient will state at least one thing learned about the importance
of activity tolerance in the older adult by the end of the clinical day.
Nursing Interventions Scientific Rationale Evaluation
Determine patient’s Establishes a baseline Assessed the patient’s response to activity during
response to activity. and facilitates further bathing. Patient exhibited dyspnea on exertion
Note reports of dyspnea, interventions when repositioning; and increased fatigue and
increased weakness and (Ignatavicius & blood pressure (150/90) during bathing. BP came
fatigue, changes in vital Workman, 2015). back down to his baseline of 140/70 when
signs during and after resting.
activities. I would recommend not rushing but efficiently
(Independent/Secondary) getting bath and skin assessment done to not
upset or tire out patient.
Encourage patient to “Rushing increases The patient able to perform with minimal
pace activities and dyspnea, fatigue, and assistance: brushing his own teeth, walking to
perform as much self- hypoxemia” the bathroom, and washing his underarm area;
care as possible. (Ignatavicius & with breaks, in between to pace activities.
(Independent/Secondary) Workman, 2015, p. I would recommend always asking if he/she
565). would like to do any particular ADL before just
doing it for them, to promote independence.
Assist the patient with “Energy conservation Patient did not want to complete a full daily
determining a typical is the planning and schedule but stated he’ll make sure to add
daily schedule, including pacing of activities periods of rest throughout the day. Establishing a
tasks and activities, with for best tolerance and structured daily schedule that promotes activity
periods of rest. minimum discomfort” tolerance, was stressed to the patient.
(Independent/Primary) (Ignatavicius & I would recommend making sure patient’s pain
Workman, 2015, p. is managed before educating; as they may not be
565). as absorbent of the teaching if in pain.
Refer to occupational Can be helpful in in Explained to the patient how overall health and
therapy as well as identifying techniques lifestyle influences activity, which ultimately
lifestyle and overall and maintaining impacts well-being. Patient responded with, “I
health programs/classes control in everyday know there are things I should change but
to assist with adaptive life (Ignatavicius & sometimes I feel like it’s not even worth it; at
tools. Workman, 2015). this point in life.” Talked to patient and his wife
(Collaborative/Tertiary) about going to occupational therapy to learn and
maintain safe body mechanics; and to implement
age appropriate activities. Patient stated, “I’ll
 think about it. I move around just fine with my
walker when at home.”
I would recommend listening to your patient,
teaching/encouraging them, but not pushing too
hard if they’re not quite biting; to not lose the
rapport gained.

Implement oxygen “Oxygen therapy is Oxygen did not need to be implemented. Patient
during periods of high prescribed for both worked on his incentive spirometry to strengthen
energy use. acute and chronic his chest expansion. Patient also took frequent
(Dependent/Secondary) breathing problems breaks in between activities; as to not overexert
when the oxygen too much energy.
needs of the patient I recommend knowing your patient’s baseline
cannot be met by and anticipating the need for oxygen. If a
atmospheric or room doctor’s order has not been placed, use oxygen
air alone” in case of an emergency and then get the order.
(Ignatavicius &
Workman, 2015, p.
514).

Outcome/Goal: Patient will verbalize his beliefs on the importance of choices and
what they mean to him while in the hospital; by the end of the teaching session.
Nursing Interventions Scientific Rationale Evaluation
Promote a safe and “Provides Established a rapport with the patient by being
hopeful environment. opportunity for attentive and easily approachable. Explained to
(Independent/Secondary) patient to discuss the patient that I was there the whole day to lend
concerns/thoughts an ear if needed. Patient felt comfortable enough
freely” (Doenges, with me to talk about how depressed he was
Moorhouse & Murr, feeling and how his old age makes him feel
2010, p. 279). useless at times.
I would recommend once rapport is established to
not lose it as trust would be hard to obtain again
with the patient.
Implement medications “It can impair the Wellbutrin, used as an antidepressant in this case,
to help with mood, reserve capacity of was administered in the AM by the student nurse
depression, and stress. older adults and and clinical professor. Observed the patient
(Dependent/Secondary) lessen their ability to becoming more talkative and making jokes
respond and adapt to towards the end of the day.
changes in their I would recommend talking to the patient about
environment” non-pharmacological ways of coping with mood
 (Ignatavicius & swings, depression, and stress. Some people are
Workman, 2015, p. fixated on medications being the answer to their
12). problems. But much research has shown things
like, guided imagery and nature has decreased
these unhappy feelings as well.
Determine usual ability “Provides baseline Asked the patient questions like, “who usually
to manage own affairs. for understanding makes his medical decisions, does he feel
(Independent/Secondary) patient’s decision- comfortable making his own decisions, does he
making process and feel like he leaves it up to his wife?” Patient
measures growth” answered by saying, “I know what I want and
(Doenges et al., how to make decisions for my health, but I just
2010, p. 279). always need to know what my wife thinks. She
knows me best and can tell me if I’m wrong.”
I would recommend talking about this topic with
the wife present, so she can hear from her
husband’s perspective, how he’s feeling and why.
Maybe if she actually hears that he solely depends
her, she may realize that at times she should take
a step back; and let her husband take control.
Encourage recognizing “Individuals with an Implemented the questions as stated above.
own inner control in internal locus of Encouraged the patient to not ponder about such
decision-making. control believe they situations for weeks; and that his gut decision
(Independent/Primary) have some degree of would be the best. Explained that there’s no harm
control in outcomes in consulting with his wife, as he should, but
and that their own rather talk to her with his options laid out; and not
actions/choices help her laying them out for him.
determine what I would recommend not to come off as putting his
happens in their support system (the wife) down; but rather
lives” (Doenges et allowing him to realize inner control along with
al., 2010, p. 279). his wife’s input will strengthen decision-making.
Encourage and refer to Enhances and There’s not much educating one can fit in a day,
stress management improves use of without the patient feeling overwhelmed.
and/or assertiveness skills to aid in Suggested to the patient that he joins a support
classes. resolution of group that may help with the stress, depression,
(Collaborative/Tertiary) situations (Doenges and mood swings. These foundational aspects of
et al., 2010) his life may alter his ability to make important
decisions. Also, explained to the patient that if he
felt he needed help with speaking up, that
assertiveness classes are also an option.
I recommend stressing the importance of taking
care of yourself, not just physical but mentally
and emotionally as well. It would enhance all
aspects of one’s life.
 Nursing Diagnosis #1: Ineffective airway clearance related to increased and retained
secretions as evidence by dyspnea, rhonchi breath sounds, and ineffective cough.

Assessment
The use of accessory muscles, chest x-ray yielding evolving right lower lobe pneumonia,
prescribed Mucomyst and Albuterol nebulizer solutions, shortness of breath, high Neutrophils at
77, low lymphocytes at 11, and the depth of respirations.

Nursing Diagnosis #2: Activity intolerance related to imbalance between oxygen supply and
demand as evidence by dyspnea on exertion.

Assessment
Shortness of breath, tachycardia in response to activity-150/90, patient stating, “Just a quick
break before we turn again. I’m out of breath,” increased fatigue upon movement, and
rapid/irregular rhythm of respirations.

Nursing Diagnosis #3: Impaired emancipated decision-making related to indecisiveness and

despair as evidence by over-concerned with opinions of others and verbalization of
depression.

Assessment
Patient stating, “I need to just talk to my wife, and see what she thinks is best,” “Sometimes, all
of this is too much for me to process,” prescribed Wellbutrin, and an anxiety rating on a 1-10
scale at an 8.
 References

Doenges, E.M., Moorhouse, F.M., & Murr, C.A. (2010). Nurse’s pocket guide: Diagnoses,

prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.

Ignatavicius, D. D., & Workman, M. L. (2015). Medical-surgical nursing: Patient-centered

collaborative care. St. Louis: Elsevier Saunders.

Woods, A. D. (2010). Pneumonia. Nursing2010, 40(10), 46.

doi:10.1097/01.NURSE.0000388272.06060.8b