Question

CASE STUDY FOR CARE PLAN

Mr. W is an 83-year-old man who was brought to the hospital from a long term care facility by paramedics after reporting severe dyspnea and shortness of breath. He has been experiencing coldlike symptoms for the past 2 days. He has a productive cough with thick greenish sputum.   

When Mr. W awoke in the nursing home, it was found that he had difficulty breathing even after using his albuterol (Proventil) metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress.  

His history includes chronic obstructive pulmonary disease related to smoking 2 packs of cigarettes per day since he was 15 years old. He also has a history of HTN and coronary artery disease. He had bypass surgery 15 years ago. Mr. W is a widower, his wife died 8 years ago. Mr. W has 2 grown children and several grandchildren who visit him weekly. His last occupation was a construction worker.  

Initial vital signs:

Blood pressure 154/92 mm Hg

Heart rate. 118 bpm

O2 saturation. 88% on 1 L/min oxygen by nasal cannula

Respiratory rate. 38 breaths per minute

Temperature. 100.9 F (38.3 C)

In the ED, Mr. W undergoes a chest x-ray and admission labs are obtained including an electrolyte panel, CBC, and arterial blood gas. A sputum sample is sent to the lab for gram stain and culture and sensitivity.  

RESULTS:

CBC. WBC 12000 mm3

HGB . 11.6 g/dL

HCT . 35.2 %

Electrolytes

Glucose . 122 mg/dL

Potassium . 4.1 mEq/L

Sodium . 135 mEq/L

ABG

PH 7.32  

PaC02 . 55.4 mm Hg

Pa02 51.2 mm Hg

HC03 . 38 mEq/L

Chest Xray - results show abnormal air collections within the lung, lung hyperinflation, and lobular consolidation.  

Assessment:

Pt is awake but drowsy. Auscultation of lungs notes bilateral crackles and decreased breath sounds. Pt reports pain of 3 out of 10 when he takes a deep breath.  

Medications:

Proventil (Albuterol)

Lasix

Antipyretic

Appropriate antibiotic for probable pneumonia/lung infection

Anti-hypertensive medication

DIRECTIONS:

Each section of the care plan must be completed unless if not applicable. (no handwriting all typed).

NOTE: There must be 3 Nursing diagnoses (2 physical and 1 psychosocial). Nursing diagnoses must be NANDA approved.

Nursing Process Care Plan

Client Initials:		Culture/Ethnicity:		Support System:
Unit:	Room/Bed:	Religion:		Occupation:
Age:	Sex:	Language:		Current Work Status:
Weight:	Height:	Marital Status:		Highest Grade Completed:
Primary Patient Complaint:		Patient Medical History:
Diagnostic Procedures (Not to include labs):			Surgical Procedures: None
Pathophysiology/Etiology (Theory): Define patient primary problem and cause(s).			Supporting Symptomatology: What patient data supports your selection of Pathophysiology
Developmental Stage (Theory): Utilize Erikson. Identify what stage is applicable to your patient based on their age.			Developmental Stage (Actual): Identity what developmental stage your patient[- is ACTUALLY in. Describe behaviors/concerns that support your selection of this Developmental Stage.
Vital Signs/Frequency:

ASSESSMENT Subjective/ Objective	NURSING DIAGNOSIS #1 (Psychosocial)	PLANNING/ OUTCOME (Client-Centered) 1 Short Term 1 Long Term	INTERVENTIONS (Nurse Centered) 1 Monitoring, 1 Action & 1 Teaching per Goal	RATIONALE FOR INTERVENTIONS 1 per Intervention	EVALUATION (Evaluate each Goal)

Answer 1

Client initials: W

unit: ( not given)

Age: 83 years

weight: ( not given)

primary patient complaints: Severe dyspnoea and shortness of breath, chest pain, cough with greenish sputum

Past medical history: History of hypertension, COPD, Coronary artery disease

Surgical procedures: 15 years before patient undergone Bypass sugery

Diagnostic procedures: Chest x ray , Arterial Blood Gas analysis, Blood test for electrolytes and Heamatocrit

Sputum test for Culture and sensitivity test and gramstaining

etiology: COPD, hypertension, lung infection

Developmental stage: Older adulthood ( above 65 years) and it is the stage of Ego integrity Vs despair

Vital signs:  

Temperature : 38.3 degrees Celsius

pulse : 118 beats / mim

Respiration : 38 breaths / minutes

Blood pressure: 154/ 92 mmof Hg

Care plan

Nursing diagnosis

Psychosocial

1. Anxiety related to hospitalization or health status as evidenced by anxious appearance of the patient.

Outcome: Patient demonstrates the ability to reassure self/ Patient has facial expressions and gestures that indicates or reflects decreased distress

short term goal: patient describes own anxiety( anxious feelings) and owncopying mechanisms

Long term goal: Patient demonstrates ability to reassure self.

Nursing interventions ( with rationale)

* Assess the patient's level of anxiety : to get the base line data ( to identify the anxiety level: mild, moderate, severe. Mild anxiety reports some nervousness but moderate anxiety affects vital signs)

* Assess physical symptoms of anxiety: to identify the presence of any physical reactions or psychosomatic disorders

* Assess the copying mechanisms and defence mechanisms of the patient :

Defense mechanisms are used to protect the ego and manage anxiety.

* Recognize awareness of the patient's anxiety: Acknowledgement of patient's feelings conveys the acceptance of those feelings.

* communicate or interact with people in a peaceful manner: Patient's feelings of stability increases in a peaceful and calm environment.

* Assist the patient in developing new anxiety reducing skills such as positive imagery, relaxation and   deep breathing. : to help the patient to develop anxiety managing skills.

* Use touch ( with permission), presence , encourage verbalization and clarification of doubts :   to remind the patient that they are not alone. Being approachable promotes communication.

Nursing Diagnosis ( Physical)

1. Ineffective airway clearance related to tracheal or broncheal inflammation, edema / increased sputum production as evidenced by dyspnoea and cough with sputum production , increased respiratory rate, decreased breath sounds and crackle sounds

outcome: Patient maintain patent airway with breath sounds clear.

Nursing interventions

* Monitor respiration: rate , depth, breath sounds : to get the baseline information about respiration

* Observe sputum,it's viscosity, colour and odour : changes in sputum characteristics indicates infection.

* Elevate head of the bed: promotes chest expansion and easiness of breath

* Change the position frequently : helps in expectorations of secretions

* Administer medications as per prescription: to reduce dyspnoea

* Administer humidified oxygen as per instruction : to decrease respiratory distress

Nursing diagnosis ( 2)

Impaired gas exchange related to collection of mucous in airways/ inflammation of airways and alveoli as evidenced by tachypnoea and tachycardia/ hpoxemia

Outcome :

Patient will demonstrate improved ventilation and oxygenation of tissues ( ABG s within normal range )

Interventions

* Assess respiration, colour of skin and mucous membrane: bluish discoloration of skin and mucous membrane indicates cyanosis

* Encourage bedrest and relaxation: minimizing activities reduces the demand of oxygen and energy

* Encourage relaxation techniques, deep breathing and coughing exercise : to reduce anxiety and to improve ventilation

* Administer oxygen, humidified as per instruction: to increase oxygenation to the tissues