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Nursing Care Plan Using the Nursing Process

Student Name: Kaitlyn Kelley Date: 18 March 2013 Client Code Name: BA Implementation (Nursing
Interventions with NIC Intervention Label & Page #Must be Tailored to Your Client)

Nursing Diagnoses/Analysis (List


Top 3 Nursing Diagnoses in Order of Priority Using 3-part statement for actual nursing diagnoses)

Planning (Expected Client


Outcomes- Must Include Teaching/Learning Outcome for 4430)

Evaluation (Evaluate Each


Expected Client Outcome- If Not Met Discuss Reason and Proposed Changes in Client Care)

(Ackley and Ladwig, pg 144146) Anxiety r/t not being able BA will identify and to breath AEB patient verbalize situations that report. cause anxiety by end of shift. Anxiety Reduction: Discuss with patient the predisposing situations to cause anxiety. BA will identify, verbalize, Educate patient and and demonstrate necessity of wearing O2 techniques to manage per doctors orders to this anxiety by end of decrease situations when shift. she is unable to breath thus causing the anxiety, BA will verbalize ways to which decreased ability decrease the anxietyto breath. causing situation by end Discuss with patient ways of shift. to maximize breath and control breathing; such as full, deep breaths instead of breathing solely into the chest. Encourage the patient that they can overcome the anxiety with proper prevention and
Version: Aug. 26, 2010

Outcome met: Patient verbalized what causes the anxiety. Outcome met: Patient demonstrated controlled breathing that helps to regain control. Outcome met: Patient recognizes the need to maintain 24 hr oxygenation per doctors orders.

Nursing Care Planning and Clinical Reasoning Form Page 1

Nursing Diagnoses/Analysis (List


Top 3 Nursing Diagnoses in Order of Priority Using 3-part statement for actual nursing diagnoses)

Planning (Expected Client


Outcomes- Must Include Teaching/Learning Outcome for 4430)

Implementation (Nursing

Interventions with NIC Intervention Label & Page #Must be Tailored to Your Client)

Evaluation (Evaluate Each


Expected Client Outcome- If Not Met Discuss Reason and Proposed Changes in Client Care)

management. Validate the patients fear and praise for days without anxiety. Educate patient on when to contact medical support during an anxiety attack. Educate the patient to keep track of anxiety in a journal recording the attack, length, what caused it, and how it was managed. (Ackley and Ladwig, pgs. 431-434) Ineffective self-health management r/t perceived benefits AEB failure to include all treatment regimens in daily life thus needing to be hospitalized. BA will identify necessary treatment regimens that she is meeting at home as well as where she is lacking compliance by end of shift. BA will verbalize ways to incorporate management into daily life at home by end of shift. BA will verbalize
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Establish a collaborative partnership with the client for purposes of meeting health-related goals. Actively listen to how she is currently managing her illness at home. Help to patient to identify and modify barriers to self-management.
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Outcome not met: BA reports I do everything my physician tells me and also reports not wearing O2 as ordered. Continue to review importance of regimen. Outcome met: BA reports ways to include management.

Nursing Diagnoses/Analysis (List


Top 3 Nursing Diagnoses in Order of Priority Using 3-part statement for actual nursing diagnoses)

Planning (Expected Client


Outcomes- Must Include Teaching/Learning Outcome for 4430)

Implementation (Nursing

Interventions with NIC Intervention Label & Page #Must be Tailored to Your Client)

Evaluation (Evaluate Each


Expected Client Outcome- If Not Met Discuss Reason and Proposed Changes in Client Care)

importance of notifying her physician if she feels she cannot comply with treatment regimens in order to discuss a new regimen if possible/necessary by end of shift.

Educate on the consequences of noncompliance. Teach BA to act as a selfadvocate with health providers who prescribe therapeutic regimens.

Outcome partially met: BA understands consequences of noncompliance. Continue discussion and notify physician if further concerns exist.

Reflection and Critical Thinking Questions Based on QSEN Competencies (http://www.qsen.org): 1. What are your personal views on todays clinical experience? What would you do differently to be more successful with your client? What quality improvement methods could be instituted to improve the clients quality of care and safety? Safety is an important part of patient care because the goal is to improve the patient so that they can leave the hospital in an improved state. Some of the patient concerns involve keeping the floor clear of wires so that a patient does not trip and fall while getting out of the bed or ambulating. It is also important to make sure that the call bell is with in reach and you leave the bed in a low position so that they can get out of bed without falling. BA preferred to sit in the chair instead of lay in bed. For this reason, I had to be sure that the call bell was placed on the bed in a position she could easily access. Also, the nasal canula occasionally would pull to one side due to the distance between her and the oxygen port. To decrease the pull on the patient, I taped the tubing to the bed in a position that she could undo the tape if she needed to ambulate, but it would decrease the pull on her nares. Other safety involved is in checking the patients armbands and having them recite their name and birthday before administering medication. Giving the wrong medication to the wrong patient can cause errors. Though the computer helps with all the barcodes to confirm that the medication match the MAR and the patients wristband. It is important to confirm with the patient their name and birthday. As she ate food from home, it is important to assess her understanding of her dietary requirements in order to ensure that she was not eating foods that would
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increase the complications with her current medical situation. As she is concerned about her weight and is interested in lap band surgery, I could have assisted her to make arrangements with her primary care doctor in order to address this concern of hers. To improve her care, better organization of visits from doctors, nurses, CNAs, nutrition team, and other members could occur in order to increase her ability to rest in between visits. This would be difficult to do as they all have many tasks and patients. It would also be important not to overwhelm her with information or over exhaust her. She also did not always alert the nurse, CNA, or myself when she needs to ambulate. There are reminders around the room that say call before you fall, but to decrease the risk, the CAN or I could have entered her room frequently to offer to assist her to the restroom instead of her deciding to ambulate without help. 2. Discuss your clients disease pathophysiology and relate it to the assessment findings (including vital signs, laboratory results, and medications). Please support your answers using appropriate nursing literatureincluding nursing research and evidence based practice literature. Based on your clients current pathophysiology or personal/family disease history, describe the genetic or genomic education, screening, or referral that you could perform with your client/family during your nursing care. BA came in due to an exacerbation of COPD. She has had COPD for many years. COPD stands for Chronic Obstructive Pulmonary Disease. This occurs where airflow is obstructed due to asthma, bronchitis, or emphysema. These inflammatory changes causes an impaired gas exchange related to overdistended alveoli. It also affects the ciliary function. Typically, it increases a patients hemoglobin levels related to an increased demand to carry oxygen, but BAs hemoglobin levels were low. Due to the decreased perfusion, it causes an decreased pH, increased pCO2, decreased O2, and increased pHCO3; which BA exhibited. The manifestations of COPD are dyspnea, cough, shortness of breath, tychypnea, abnormal breath sounds, decrease muscle mass, barrel chest, and clubbing of the nails. An exacerbation is a flare up of symptoms that is more than her day to day regular. She has asthma and had a 50 pack year smoking history which plays into her COPD. She does not smoke now. This is managed with 3.5 L of oxygen at home and a BiPAP machine while she sleeps due to her obstructive sleep apnea as well. Her dyspnea could be due to this or to her pulmonary hypertension. A chest x-ray displayed that her heart was enlarged. This could contribute to the edema as the heart function is altered due to a change in size. As COPD is a risk factor for CHF, it is important to monitor her heart function. Her cardiac enzymes are within normal limits. Her liver function tests are abnormal due to an elevated AST, however the rest are within normal limits. This may be due to her obesity and DM because it adds stress on the liver, especially if they liver becomes fatty. These tests should be rerun in two months is the physician suspects liver damage or altered liver function. Her ABG labs are outside of normal limits in a way that reflects a COPD exacerbation and contributes to her dyspnea due to an
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impaired gas exchange. She had been having a clear productive cough at home but it has cleared up since being in the hospital (Smeltzer, Bare, Hinkle, & Cheever, 603-613). 3. What were your client/familys educational needs and what strategies did you use to meet the needs? How did you utilize informatics to educate your client/family? What did you document about your education success or difficulties today? As a diabetic, it is important to know her blood sugar before eating to determine if insulin needs to be administered. The finger stick glucometer is used in order to obtain this information. She knows her regular levels and is able to plan for her meals accordingly. Insulin was held both at breakfast and at lunch as they were beneath 150. The electronic blood pressure and heart rate cuff and thermometer also were helpful in monitoring her current health status. As she has pulmonary hypertension it is important to monitor her blood pressure and inform her of it. As she had edema in her legs, she could compare her previous weight to her current weight using the scale in order to obtain an estimate of how much weight she has gained from fluid retention. The armband also has a bar code that can be swiped by the electronic medical record system prior to giving medication. This allows for a decrease in risks of giving the wrong medication in terms of the right patient part of the 6 rights of medication (dose, route, drug, time, patient, documentation). Each medication is also scanned by the electronic medical administration record. As she was on humidified air, the oxygen level was controlled through the pump. I discussed with the patient to necessity of using her oxygen at home to ensure that she remains able to breathe well and avoid anxiety attacks. She also uses a BiPAP machine for her obstructive sleep apnea. The call bell allows her to communicate with the secretary. This allows her to have her needs met and this way she can ambulate to the restroom with assistance when she can alert the CNA or nurse. 4. Discuss 3 patient-centered care actions that you performed today that demonstrated caring towards your client/family. Were they based on the client/familys preferences, values, and needs? - As she prefers to eat food from home. It was patient-centered care to help her to prepare them. For lunch that included heating up her soup for her and ensuring that it was a safe temperature. She still got the lunches and would pick around on them for food that she still enjoyed. However, I was aware that she preferred it to be taken off her table when she was done. I ensured that she was still eating a proper amount of food and we discussed her diet to ensure that she understands what is allowed on her diet.

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- When I came in the morning, her oxygen was running at a higher rate than ordered and it was bothering her. As I introduced myself and did a general check and asked how she was feeling, she noted that her nose was bothering her. I noted that it was flowing at 5 L/min and ensured her that I would return soon after talking with her nurse about the orders. I knew that as a COPD patient experiencing an exacerbation her O2 would be higher than 2 L/min, but it seemed high. After discussing with the nurse and checking her orders, we discovered that it was supposed to be at 4 L/min and the fluid for humidified air was also low. After correcting these things with the nurse, she expressed that she was breathing easier and was not experiencing pain in her nose. - Though she was a transfer with assistance she was fully capable of all ADL that did not require walking. For this reason, I prepared warm water in a basin and gathered her toothbrush, soaps, and washcloths in order for her to wash her face and brush her teeth in the morning. By allowing her to provide this care for herself, it continues to give her control of her life even though she is hospitalized. I then left the room in order to give her privacy, as she would have in her home, as she got ready for the day. I made sure to come back into the room a few minutes later in order to clear it from her tray so that she could return to using her computer instead of getting distracted and forgetting and leaving her with her morning supplies in her way. 5. Discuss how inter-professional teamwork & collaboration was used to care for your client or discuss how your client might have benefitted from better inter-professional teamwork & collaboration practices. There are many members of the medical team that help to provide well rounded and thorough care to the patients. The nurses provide a constant interaction and support system for the patient as well as involving the family in care. The doctors communicate with the pharmacy to get medications approved for the patient that the nurse can then administer. The secretary keeps the nurse available to the patient and assists in coordinating information between the doctors and the nurses as well. The tech participates in the team by providing patient interaction, recording vitals, and assisting with activity of daily living. A member of the transportation team would accompany my patient to diagnostic tests such as her chest x-ray. A phlebotomist draws blood in order for the lab to analyze the components and input it into the computer for the nurse and doctor to look over. The nurse uses this information to administer or hold medication as well as monitor health status. The doctor uses the medication to plan treatment options and prescribe medication and diagnostic tests. Respiratory therapists give nebulizer treatments to my patients and assess respiratory status. . The environmental staff decreases contamination by sanitizing the floors, emptying trash, and providing and clean and aesthetically pleasing environment for the patients. They also keep the nutrition room stocked in order to provide that patients with crackers and sodas. The nutrition team delivered food to the patients as well as take orders for meal. However, my patient did not eat the meals provided as she had food from home in her refrigerator.
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References Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: an evidence-based guide to planning care (9th ed., pp. 269-271, 210-215). St. Louis, MO: Elsevier Mosby. Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Management of patients with chronic pulmonary disease. In Textbook of medicalsurgical nursing (12th ed., Vol. 1, pp. 603-613). Philadelphia, PA: Lippincott Williams & Wilkins.

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Version: Aug. 26, 2010