Nurse Education Program Concept Mapping 2

Nurse Education Program Concept Mapping: 2 Subjective Assessment Objective Assessment -Pt stated has been smoking since “12 years old” -Pt stated he does not like cooking for himself -Pt does not have much family support -Pt drove himself to the hospital -Pt says he has a hard time completing tasks (ADL’s) because he is consistently SOB -Pt stated there is no need to change his habits because he doesn’t have anyone in his life he cares about -Pt reports fatigue due to lack of sleep within 24 hours -Pt reports no pain Pertinent Medications Insulin Sliding Scale Glucotrol 2.5mg Flora-Q 1 cap Aspirin 81mg Lipitor 10mg Plavix 75mg Lisinopril 20mg Metformin XR 1,000mg Methylprednisolone 40mg Lovenox 40mg Nicotine Patch Robitussin 5mL Levaquin 750mg Client 72 y/o, Male Community Acquired Pneumonia, COPD exacerbation, elevated troponin levels, ischemia, and GI and DVT prophylaxis No known allergies Pertinent Labs WBC: 12 Hbg: 13.9 Hct: 40.9 Sodium: 134 Potassium: 3.9 CO2: 21 Glucose: 174 BUN: 18 Troponin: 0.03 HDL: 37 LDL: 80 Nursing Diagnosis 1: Ineffective airway clearance related to increased sputum and the airway damage due to smoking as evidenced by chest x-ray indication of community acquired pneumonia shortness of breath productive cough patient restlessness difficulty Coexisting Health Problems Coronary Artery Disease Aortic Valve Replacement (Biosynthetic) COPD Active smoker w/ production of sputum Hypertension Hyperlipidemia Diabetes Mellitus Type 2 B/P: 124/61, 96/54, 117/71 Temp: 97.2, temporal Pulse: 56BPM Resp: 16BPM O2 sat: 95% Pain: 0/10 Glucose: 174 -100kg, 178 cm, 31.5 BMI -Wheezing on inspiration and expiration, rhonchi bilaterally -Pt SOB while resting and after ambulation -Pt is independent -Pt seemed restless -4x Bowel Sounds -Pt has loose cough -Alert and Oriented x3 -Weak radial pulses -Capillary Refill 3 seconds Data Gaps -Patient’s discharge plans, anyone to care for him at home? -Did patient become more knowledgeable of illnesses? Nursing Diagnosis 2: Decreased cardiac output related to negative inotropic changes in the heart as evidenced by hypotension (96/54), heart rate of 56, weak radial pulses, patient fatigue feeling short of breath ischemia from previous MI decreased sodium level of 134 n Pro Evaluation 1: Student nurse monitored and auscultated breath sounds, rate and depth of respirations, but was unable to see if the outcome was met. Student nurse educated patient on the benefits of quitting smoking, but the patient said he has smoked too long and does not want to quit, but will use the nicotine patch. The patient liked the idea of sitting in a semi-Fowlers position while sleeping and how he already felt like he was not as short of breath. The student nurse educated patient on cough and deep breathing will help improve airway clearance, and the patient demonstrated. The patient did not use an incentive spirometer with the student nurse, but said he has used them in the past. The patient said the tool “was difficult” to use. The patient was receptive on completing use of Methylprednisolone and Levaquin to help with his breathing. Goal was met. Evaluation 2: Student Nurse monitored blood pressure and pulse rate and rhythm and observe improvement of these values of blood pressure to 117/71. Student nurse educated patient on spacing out ADL’s to promote eupnea, so the patient relaxed after using the bathroom or talking to staff members. Student nurse educated patient on understanding the need to promote healthy eating habits, such as less saturated fats and leaner meats. The student nurse was also able to provide options for the patient to promote healthier eating habits, like cooking more homemade meals and meal options at grocery stores, and patient was receptive and said he considers making these changes. The student nurse recorded input and outputs and taught the patient to report these too. Patient said he usually takes blood pressure readings prior to administration of Lisinopril, and is adherent to his medications. Patient says he has a pill separator to keep things on tract. Patient believes the nicotine patch will help for a while, and said he “will see” about cessation of smoking. The student nurse was not able to determine if the goal was met prior to discharge. Nurse Education Program Concept Mapping: 2 Analysis and Synthesis for Ineffective Airway Clearance: This diagnosis is appropriate for the patient because the patient presents with community acquired pneumonia, COPD, and smokes. When the patient smokes, it kills the ciliary, which are responsible for moving mucus through the lungs and it limits the elasticity of the lungs. This demotes effective breathing and can cause respiratory blockage. The patient developed COPD, so breathing is also depleted. Since the patient has an infection, these three main factors cause the patient to have an ineffective airway clearance. Rationale: 1) Auscultating patient’s lung sounds and assessing the rate and depth of respirations are good assessment findings to indicate a change of airway. A decrease in breath sounds of an increase in adventitious sounds, a change in mental status, restlessness, and use of accessory muscles may indicate a change in the respiratory status and a need for an intervention (Hinkle & Cheever, 2014). 2) Cessation of smoking will always help decrease complications of breathing patterns and promote a more effective airway clearance. Inhalation of toxic or chemical irritants will damage the cilia and lung tissue, which will decrease the motility of mucus and sputum and is an indicator for developing pneumonia. The se of the nicotine patch provides the patient with nicotine, but has less of an effect on the lung tissue and is an initial step in the process of cessation of smoking (Saunier, 2017). 3) Promoting the patient to sit in a semi to high Fowlers position promotes comfort, optimal gas exchange, and a position to excrete airway plugging by enabling maximal chest expansion, activating accessory muscles during inspiration and promote gravity during expiration (Henry et al, 2016). 4) Since the patient has COPD, pneumonia, and lives alone it is important to teach the patient to separate ADL’s and certain activities throughout the day to decrease shortness of breath and promote eupnea (Saunier, 2017). 5) Cough and deep breathing and use of incentive spirometry helps clear airways of secretions. These controlled coughing and deep breathing exercises will ensure effective cough because it incorporates uses of the diaphragm to provide forcefulness coughing. The forceful coughing will ensure mucus clearance (Hinkle & Cheever, 2014). 6) Methylprednisolone is a corticosteroid. These drugs help decrease inflammation and help with COPD exacerbation. The use of this medication will promote an effective airway clearance (Lehne, 2016). 7) Levaquin is an antibiotic used the will help to fight off the pneumonia infection. Completing this medication will decrease the chance of resistance to the medication and killing the entire infection. If the patient stops this medication before the recommended time, the infection has a higher chance of returning and coming back stronger (Lehne, 2016). Analysis and Synthesis for Decreased Cardiac Output: The patient has coronary heart disease, had an atrial valve replacement, and has high blood pressure. These three factors put the patient at risk for decreased cardiac output. Since the patient has elevated troponin levels and shows signs of shortness of breath, hypotensive, and decreased peripheral pulses, the patient has assessment findings that lead to decreased cardiac output. Rationale: 1) Effective cardiac output is evaluated by continuous monitoring like blood pressure readings because if the patient is hypotensive, that can mean there is decreased blood output from the heart and less blood flowing through the body. Assessing peripheral pulses indicates if there is an absence or low quality reading then it can indicate that cardiac output is declining. Noting the rhythm of the heart can indicate if there is any friction rubbing or dysrhythmias (VanMeter & Hubert, 2014). 2) For discharge, it is important to teach the patient to check their own blood pressure and pulse before self-administering medications like Lisinopril to lower blood pressure. If the patient’s blood pressure is below 100 or the pulse is under 60 and the patient takes this medication, they could become extremely hypotensive and have adverse reactions (Lehne, 2016). Nurse Education Program Concept Mapping: 2 3) Lipitor is a medication used to decrease cholesterol levels. It is important for the patient to use this medication because it will decrease the chance of large amounts of cholesterol filling in the veins and arteries and potentially causes a heart block and decreased cardiac output. Plavix is used to prevent heart attacks and stroke. Since the patient has CAD and has already had a heart attack, it is important to continue taking these medications so an MI does not happen again. Cessation of both these medications can be fatal for the patient (Lehne, 2016). 4) Teaching and programs to provide information on stress management and health education have shown how reduce long term mortality rates, a recurrence of myocardial infarction, and reduce heart blocks. Diet and exercise can also help manage blood pressure and cholesterol levels (Sherwood, Hinderliter, Georgiades, & Blumenthal, 2017). 5) Monitoring input and output and weighing patient can be used as assessment findings if the patient gains weight because of decreased cardiac contractility, which can cause renal perfusion or fluid retention. This can also help manage sodium levels (Henry et al, 2016).