Nursing Process Worksheet 1

NURSING PROCESS WORKSHEET Instructions: Each clinical day you will develop a nursing process outline for one patient of your choice. It will be due by the end of the clinical day, along with a completed patient profile database form. The outline will be as follows: History of Present Illness: M.H. is an 82 year old Caucasian male who was admitted to the hospital with pneumonia in the lower left lobe accompanied by signs and symptoms of chest pain, shortness of breath, cough, and fever. Vital signs upon admission include: T: 100.8, HR 87, RR 20, BP 135/80, SpO2 92 %, and no reported incidence of pain. Patient denies any allergies. Alert and Oriented times 4. M.H. has a history of Diabetes type 2, Hypertension, and Dysphagia. M.H. now lives alone, he states he is Catholic and an construction worker. Upon further assessment M.H. is found to have hearing aids and dentures. Physical assessment of the patient include Left sided chest pain, productive cough, difÏculty in breathing increased with activities, tachypnea, resp28 bpm, oxygen saturation 91-92% on Room Air and crackles on auscultation. The abdomen is soft and non-tender and patient is continent of stool and urine. Labs ordered by the physician include: Complete blood counts every day, Basic Metabolic Panel Everyday,Chest X ray, EKG Ct scan of the chest. Medications to be continued:Cozaar 100mg by mouth daily,Metformin 100 mg PO Daily,Januvia 100 mg PO daily,Lantus 25 units SQ Q HS Azithromycin 500 mg IV daily,Levaquin 250 mg IV Daily,Duoneb unit dose nebulizer Q 4 PRN for shortness of breath,Tylenol 650mg PO Q 4 PRN for Temp> 100.8 F Pathophysiology of AdmitÝng Diagnosis – Must include pathophysiology, signs & symptoms, risk factors, complications Admitting diagnosis is pneumonia of the lower left lobe. Pneumonia is defined as an inflammatory reaction in the alveoli and interstitium space in the lungs typically caused by an infectious agent (Banasik & Copstead, 2018). Pathophysiology: Pulmonary defense systems protect against invasion of foreign pathogens. If defense systems are weakened, or overwhelmed, a pathogen may enter the lung, multiply and grow triggering the inflammatory response. Alveolar spaces fill with fluid, causing inflammation of tissue, and decreased exchange of gases due to lowered surface area, leading to hypoxemia (Banasik & Copstead, 2018). The exudate continues to infiltrate alveolar spaces causing difÏculty breathing. Signs and symptoms: Left sided chest pain, productive cough, fever, dyspnea, difficulty in breathing increased with activities, tachypnea, a respiratory rate of 28 beats per minute, oxygen saturation 91-92% on room air and crackles on auscultation. Risk factors: Patient’s advanced age (87 years old), chronic illness including type 2 diabetes and hypertension. Complications: Patient is currently experiencing difÏculty breathing. If oxygen saturation does not improve, patient may need to be placed on a ventilator(Taylor et al., 2018). Fluid accumulation within the lung is evidenced by crackles; if condition worsens may require drainage. Vitals should be monitored to evaluate for bacteremia. Nursing Diagnosis (2) Must be prioritized NANDA using three part statement (based on abnormal assessment findings) Nursing DX  Related To: Etiology (Cause)  As evidenced by: signs and symptoms from assessment NANDA #1 Ineffective airway clearance related to bacterial pneumonia as evidenced by shortness of breath, fever, productive cough, and chest pain. NANDA #2 Activity intolerance related to bacterial pneumonia as evidenced by difÏculty in breathing increased with activity, increased respiratory rate, and 92% oxygen saturation on room air. Nursing Risk for Diagnosis (1) – Must be priortized NANDA using three part statement (based on assessment findings) “Risk for…” Nursing DX  Related To: Etiology (Cause) Risk for NANDA #1 At risk for fall related to general weakness and unsteady gait. Planning/Patient Goals: 1 for each nursing diagnosis (3 total) Must be SMART (Specific, Measurable, Achievable, Realistic, Timeframe) and start each with “Pt. will… “ Goal #1 Patient will achieve airway clearance within a 72 hour period as evidenced by absence of dyspnea and crackles. Patient will demonstrate ability ambulate without reported fatigue within a 48 hour time period. Goal #2 Patient will be able to demonstrate ambulating independently with the use of an assisted device upon discharge. Risk for Goal #1 Implementation – Specific nursing interventions that were performed during your shift (Must have 3 per nursing dx) NANDA #1 1. Position the patient in a Semi-Fowler position Rationale: An elevated position would allow for greater chest expansion, lower the diaphragm, promote mobilization, increase the ability to expel secretions(Vera, 2021). 2. Demonstrate breathing exercises for the patient Rationale: Deep breathing allows for greater expansion of lung tissue causing greater oxygenation of tissue and increase in expectoration of mucous(Vera, 2021). 3. Maintain hydration using 2000-3000 mL of fluid a day Rationale: Fluids moisturize the airway causing ease of expectoration of secretions. Hydration allows for thinning of the secretions and reduction in thickness of mucous (Vera, 2021). NANDA #2 1. Encourage ambulation Rationale: Reduces the risk of atelectasis and promotes the expulsion of secretions (Vera, 2021). 2. Use a nebulizer treatment Rationale: Nebulizers are used to humidify the airway leading to the breakdown of thicker secretions, allowing thin secretions to be coughed and expelled(Vera, 2021). 3. Supplemental oxygen Rationale: Used to increase oxygen saturation levels to appropriate baseline of 95-100%. Supplemental oxygen can reduce incidence of hypoxemia (Vera, 2021). Risk for NANDA #1 1. Bed at lowest possible position Rationale: Reduces risk for fall or injury when trying to ambulate (Vera, 2021). 2. Bed alarms Rationale: Alarms signal to nursing staff that patient is trying to ambulate without assistance (Vera, 2021). Patient may remember to call for assistance when ambulating when alarm is set off if hearing aids are present. 3. Ensure clear path without obstructions Rationale: Patient is not skilled at walking around objects and may need a clear path to reduce the risk of falls (Vera, 2021). Evaluation – What was the outcome? Goal met | Goal not met | Goal partially met and how to revise/recommend Must have 1 evaluation per goal 1. Goal was met. Patient drank 3000 mL of fluid, practiced deep breathing exercise, and remained in a Semi-Fowler position leading to cough productivity and successful expectoration of secretions. 2. Goal was partially met. Patient complained of fatigue when ambulating and could only ambulate to the restroom. Nurse will encourage shorter periods of ambulation to decrease fatigue.Patient was able to meet goal of nebulizer therapy for bronchodilation and supplemental oxygen to decrease hypoxemia. Nursing Application Assessment Include activities throughout the day performed in relation to the following NCLEX content categories. See content category examples below as cited by NCSBN Safety and Infection Control 1. Injury prevention plan. Discuss removing obstructions to reduce incidence of falls. 2. Transmission based precautions should be used. Use of a mask to prevent droplets from infecting others. Practicing good oral hygiene and clean techniques such as washing hands can prevent spread of pathogens. Basic Care and Comfort 1. Use a walker for an assistive device to help patient with unsteady gait. 2. Promotion of mobility through ambulation (Taylor et al., 2018). Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards. Related content includes, but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic Principles, Handling Hazardous and Infectious Materials, Home Safety Reporting of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living. Related content includes, but is not limited to: Assistive devices, Elimination, Mobility/Immobility, NonPharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest and Sleep