NUR250 Nursing Care Plan NUR250 Assessment 1 S1 2017 Assignment template It is recommended you do not delete the heading and the information below. Please note: As indicated in Assessment 1 information, a cover sheet, title and contents pages are not required
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Task 1: Understanding nursing problems The respiratory problem is the core issue faced by many healthcare providers in the acute care settings. According to the handover, Neville has the core issues with his health like blocked airway, malnutrition, and possibility of infection. Neville’s airway may be affected by bronchitis because the production of thick secretions is increased due to bronchitis. The bacterial growth
may occur due to the accumulation of mucus in the airway which leads to respiratory infection and impairment of airway clearance (Ramos, Krahnke, & Kim, 2014). Impaired gas exchange of Neville may be due to emphysema because emphysema impairs the lung tissue which is responsible for gasses exchange in alveoli and collapse the airway. The exacerbation also causes deterioration of gas exchange (Lemone et al., 2017). Neville has a risk of impaired gas exchange due to smoking habit. Due to continue oxygen administration, CO2 retention may occur and it causes the loss of hypoxaemic respiratory drive and fatigue of respiratory muscles and may impair the ventilation of Neville (Lemone et al., 2017). He might have fatigue due to dyspnoea which may result in increased consumption of energy that may be unable him to take the full diet (Lemone et al., 2017). The side effect of medicines as Neville has prescribed amoxicillin antibiotic also may cause nausea, vomiting, and anorexia to him and decreased his intake (Tiziani, 2013). Due to decreased acquired immunity and chronic disease process, Neville has the risk of further infection. The malnutrition also a responsible factor to prone him at risk of infection. Moreover, the work of cilia has been decreased due to smoking and persistence secretions in airway lead to infection (Lemone et al., 2017). The acute exacerbation cause bacterial and viral infection in COPD. The hospitalization also may lead to the risk of hospitalacquired pneumonia (Müllerova et al., 2012). Task 2: Care planning Nursing Care Plan: Neville Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer A reminder that all information must be referenced Nursing problem: Activity intolerance Underlying cause or reason: generalized weakness and dyspnea Goal of care Nursing interventions/actions · Monitor vital signs closely immediately after any activity and note the abnormalities. · Ensure Neville performs daily activities and reduce the risk of respiratory distress.
· Assist Neville to perform activities of daily living (ADL).
Rationale · It helps to detect the early symptoms of deteriorating condition (Li et al., 2014).
· It helps to promote functional dependence and prevent the loss of motion and reduce the risk of fall injuries (Zarowitz, & O’Shea, 2012) · Adequate rest prevents fatigue and preserves energy (Lemone et al., 2017).
·
Provide proper rest to the patient between
treatment and activity periods.
·
Provide oxygen therapy as prescribed.
· It helps to promote activity and exercise tolerance (Lemone et al., 2017).
· Encourage patient to perform activities by giving positive feedback.
· This may help the patient to hope for activity tolerance after curin of disease (Lemone et al., 2017) · Support the patient emotionally and reassure the patient about regain of energy.
Nursing problem: Altered sleep pattern Underlying cause or reason: a persistent cough Goal of care Nursing interventions/actions
Rationale
To ensure that Neville has · Monitor sleep pattern with objective and · The subjective and objective no disturbance in sleep subjective information. data helps to assess accurate sleeping pattern time (Lemone et al., 2017). · Provide fowler’s or semi-Fowler's position to the patient.
· This position promotes the ventilation and decreases breathing workload (Lemone et al., 2017).
· Administer cough expectorants and bronchodilators as prescribed.
· These agents help to loosen an spit out the mucus in the airway and make the airway clear and patent (Lemone et al., 2017). · Relaxation therapies help to divert mind and beat the sleeping problems (Volpato, Banfi, Rogers, & Pagnini, 2015).
·
Advise the patient to perform relaxation
activities before bed. · Some medication may disturb the sleeping pattern (Lemone et al., 2017). · Check the prescribed medication of patient and if there is any drug at bedtime that interferes with sleep then consult the doctor. Nursing problem: Deficit fluid volume Underlying cause or reason: less oral intake and nausea and vomiting possible side effects of medicines. Goal of care Nursing interventions/actions Rationale
· Maintain intake and output chart of the patient. · To maintain adequate hydration of the patient.
Check weight daily.
· Check vital sign regularly- pulse rate, temperature, and respiration rate. · Check oral mucosa and skin turgor for dryness. · Assess the orientation level of the patient with Glasgow coma scale.
Nursing problem: Risk of constipation Underlying cause or reason: imbalanced diet and limited fluid intake Goal of care Nursing interventions/actions Ensure Neville get relief from discomfort during · Check the stool for consistency and defecation. frequency.
· It may help to assess the body requirements of fluid (Lemone et al., 2017). · Tachypnoea, hypotension and tachycardia indicate the risk of dehydration (McGloin, 2015). · Dryness of oral mucosa and decreased skin turgor are signs of dehydration (McGloin, 2015).
· Electrolytes imbalance may lea to disorientation.
Rationale
· This will help to know about th normal condition for the patient (Lemone et al., 2017).
· This helps to promote to natura · Encourage the patient to drink a glass of elimination (Lemone et al., 2017). warm water in morning.
· Irregular and less food intake may lead to constipation (Sun et al., 2013) · Monitor dietary habits of patient and advise taking the nutritious diet.
· Administer stool softener or bulk laxatives as prescribed.
· Laxatives relieve constipation and maintain normal elimination (Lemone et al., 2017).
· Increased fluid intake softens the stool consistency and improves intestinal movements (Lemone et al., · Consult the nutritionist for the diet chart 2017). as required. zEncourage patient to increase fluid intake.
Nursing problem: self-care deficit Underlying cause or reason: fatigue secondary to dyspnoea. Goal of care Nursing interventions/actions · Assess the ability of the patient to perform activities. · If a patient wants to walk, provide support or walker.
Rationale
· Assessment helps to plan interventions to meet particular needs (Lemone et al., 2017).
To enable the patient to perform self-care · Assist the patient in activities that need an · Minimum assistance may activities- bathing, eating, assistant. encourage the patient for self-care defecating and more on. (Lemone et al., 2017). · Provide an atmosphere that permits the patient to perform daily care independently such as clean teeth or feeding. · This may improve self-esteem · Encourage the patient to perform ADL’s and increase independence (Lemone according to his ability. al., 2017). · Allow the family members to help the patient. Task 3: Medication management Eosinophils the main cause of the COPD to exist are targeted by prednisone as a corticosteroid (Akdis, 2012). The use of prednisone must be monitored along with the check that patient
doesn’t have any fungal infection. Also, the steroid medication weakens the immune system. Neville must be briefed with the complications arising due to the use of steroids with the smoking (Tiziani, 2013). The prime responsibility of nurse during medication administration is that nurse should follow the six rights (right dose, right route, right patient, right documentation, right drug and right time) of medication administration to avoid the medication errors (Ferguson, Delaney & Hardy, 2014). Another drug Ipratropium bromide is used for the treatment of lung obstruction as it anticholinergic agent and act as a bronchodilator by reducing the airborne passages (Tiziani, 2013). Before providing the nursing intervention with the Ipratropium bromide is its contraindications to cause hypersensitivity. The possible side effects of this are tachycardia, acute angle-closure glaucoma, nausea, palpitations, and headache. The nurse should provide sips of water to the patient to avoid dryness of the mouth (Lemone et al., 2017). The excessive use through nebulizer would cause the prostatic hypertrophy in Neville. The use is required on a regular basis for the situation like that of Neville (Stephenson et al., 2011). Antibiotics are recommended to a patient with COPD to relieve breathlessness by alleviating the increased purulent sputum production and cough (Bailey et al., 2012). Oral corticosteroids are prescribed with a combination of broad-spectrum antibiotics to cure a bacterial infection. Oral amoxicillin is given to Neville in addition to prednisone for controlling the possible infection spread in lungs and to treat the bacterial infections (Brusse-Keizer, VanderValk, Hendrix, Kerstjens & van der Palen, 2014). There is a chance that Neville could be allergic to such medication so the alternative must be given in such cases. The nurse should aware of possible side effects of amoxicillin. The main side effect of it is diarrhea. Diarrhea results in the nutrition loss which must be treated otherwise situation could be worsened as Neville is already malnourished (Tiziani, 2013). Neville has prescribed oral medications because the oral route of medication administration is convenient and safe and it is the ideal route to achieve desired curative outcomes (Cyriac & James, 2014). Task 4: Patient teaching (Khdour, Hawwa, Kidney, Smyth & McElnay, 2012). Quitting smoking improves the COPD conditions. The nicotine replacement therapy or medication program could be used to help the patient recover from vulnerable smoking habits. Counseling session and group discussions must be arranged for the patients with other smokers so they can share their experiences (Hoogendoorn, Feenstra, Hoogenveen & Rutten-van MÜlken, 2010). The effect of passive smoking must also be avoided as it is more deteriorating than active smoking (Cao, Yang, Gan, & Lu, 2015). The information must be given to Neville that smoking is chief reason behind just not cancer, but also the reason for many other diseases like diabetes, cataracts, rheumatoid arthritis, and other coronary diseases (Jha & Peto, 2014). Patient-centred care is required in such cases to help him come up with the rehabilitation process and make it easy for them. Proper care and monitoring could help the rehabilitation and hence the symptoms of COPD would vanish, which helps in respiratory breathing problems (Lemone et al., 2017). Task 5: Clinical judgment and handover As per the recognition of the fact, Neville has been prescribed with salbutamol nebulizer. As a nurse, one would attend the patient and assess the situation. Seeing the condition Neville was
restless, dyspnoeic, and another parameter like high oxygen saturation, heartbeat, and depressed respiration, it has been diagnosed with hypoxia. Such situation must be considered as an emergency and patients must be elevated by 45° during supine. Ventilation must be provided, and the patient must be checked every 2 hours, to avoid complications. Hydrated oxygen must be given during the COPD condition as excessive oxygen can cause apnoea. Medication must be given to prevent any infection and monitored if granted to Neville. Slow breathing must be introduced via spirometer to improve the oxygenation I am Veerpal Kaur, a student nurse from the medical surgical ward. I am concerned about patient Neville who is 62 years old man admitted to hospital with complaints of dyspnoea, cough and increased purulent sputum. He is known case of COPD and history of smoking. He has tachycardia and slightly increased blood pressure. Oxygen is continued @2L/min as medically advised. On return to the ward, he became restless and anxious. His skin has flushed and diaphoretic. On examination, he has tachycardia and heart rate was 110 beats/minute and respiratory rate has declined to 8-10 breaths/minute. According to the condition, Neville is restless, having tachycardia and bradypnea. These are the sign and symptoms of hypoxia. All required nursing care is provided to the patient. Salbutamol nebuliser is given and nasal prong oxygen @ 2L/min continue. Medications are administered and to continue as prescribed. Intake and output chart is maintained. The close monitoring of the patient is required as per condition of the patient. The doctor's team has checked the patient and advised to transfer the patient to the High Dependency Unit to provide BIPAP support. Veerpal Kaur Dhaliwal STUDENT NURSE. Nurse Veerpal I can see you put in a lot of time and effort to research and write your assignment. You had some of your better work in Task 2 Care Plan. You have some more relevant points in some tasks, but have struggled in others. You need to work on your explanations to demonstrate better understanding of the connections between Neville’s condition, underlying pathophysiology, prescribed treatments and nursing interventions. In some sections the explanation may have not been clear due to grammar problems. Even so there could be an easy improvement in your work if you had attention to paragraphing and headings so that your work could be followed s much more easily. Try to write the answers in the terms of the question, and in an order that either follows the question, or discusses each component of the question before moving onto the next. This ensures that the reader can follow your responses, and for yourself you can see that you have answered all components of the question. You do have a good number of journal articles. There are a number of journals from medicine and other disciplines. Using these tends to deflect focus from nursing and makes it difficult to respond with nursing actions and explanations.
If you use journals from other disciplines it needs to be appropriate to the case. You will find that its easier to get nursing responses from nursing journals, and that journals from other disciplines can provide a lot of irrelevant information which side tracks students from the valuable time they have to complete their studies. The CDU Library can help you with locating and evaluating sources, referencing and using APA. References Akdis, C. A. (2012). Therapies for allergic inflammation: refining strategies to induce tolerance. Nature medicine, 18(5), 736-749. doi: 10.1038/nm.2754 Bailey, P. H., Boyles, C. M., Cloutier, J. D., Bartlett, A., Goodridge, D., Manji, M., & Dusek, B. (2012). Best practice in nursing care of dyspnea: The 6th vital sign in individuals with COPD. Journal of Nursing Education and Practice, 3(1), 108. doi: https://doi.org/10.5430/jnep.v3n1p108 Blanco, I., Gimeno, E., Munoz, P. A., Pizarro, S., Gistau, C., Rodriguez-Roisin, R., ... & BarberĂ , J. A. (2010). Hemodynamic and gas exchange effects of sildenafil in patients with chronic obstructive pulmonary disease and pulmonary hypertension. American journal of respiratory and critical care medicine, 181(3), 270-278. doi: 10.1164/rccm.200907-0988OC Brusse-Keizer, M., VanderValk, P., Hendrix, R., Kerstjens, H., & van der Palen, J. (2014). Necessity of amoxicillin clavulanic acid in addition to prednisolone in mild-to-moderate COPD exacerbations. BMJ open respiratory research, 1(1), e000052. doi: 10.1136/bmjresp-2014000052 Cao, S., Yang, C., Gan, Y., & Lu, Z. (2015). The Health Effects of Passive Smoking: An Overview of Systematic Reviews Based on Observational Epidemiological Evidence. PloS one, 10(10), e0139907. doi: http://dx.doi.org/10.1371/journal.pone.0139907 Cuquemelle, E., Pham, T., Papon, J. F., Louis, B., Danin, P. E., & Brochard, L. (2012). Heated and humidified high-flow oxygen therapy reduces discomfort during hypoxemic respiratory failure. Respiratory Care, 57(10), 1571-1577. doi: https://doi.org/10.4187/respcare.01681 Cyriac, J. M., & James, E. (2014). Switch over from intravenous to oral therapy: A concise overview. Journal of Pharmacology and Pharmacotherapeutics, 5(2), 83. doi: 10.4103/0976500X.130042 Ferguson, A., Delaney, B., & Hardy, G. (2014). Teaching medication administration through innovative simulation. Teaching and Learning in Nursing, 9(2), 64-68. Retrieved from http://www.sciencedirect.com.ezproxy.cdu.edu.au/science/article/pii/S1557308713001418 Hoogendoorn, M., Feenstra, T. L., Hoogenveen, R. T., & Rutten-van MĂślken, M. P. (2010). Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax, 65(8), 711-718. doi: http://dx.doi.org/10.1136/thx.2009.131631
Jha, P., & Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 370(1), 60-68. doi: 10.1056/NEJMra1308383 Khdour, M. R., Hawwa, A. F., Kidney, J. C., Smyth, B. M., & McElnay, J. C. (2012). Potential risk factors for medication non-adherence in patients with chronic obstructive pulmonary disease (COPD). European journal of clinical pharmacology, 68(10), 1365-1373. doi: 10.1007/s00228012-1279-5 Lemone, P., Burke, K., Bauldoff, G., Gubrud, P., Levett-Jones, T., Hales, M., ‌ Reid-Searl, K. (2017). Medical-surgical nursing, critical thinking for person-centred care. (3rd Australian ed.). Melbourne, Victoria: Pearson Australia. Li, J. M., Cheng, S. Z., Cai, W., Zhang, Z. H., Liu, Q. H., Xie, B. Z., & Wang, M. D. (2014). Transitional care for patients with chronic obstructive pulmonary disease. International Journal of Nursing Sciences, 1(2), 157-164. doi: http://doi.org/10.1016/j.ijnss.2014.05.004 McGloin, S. (2015). The ins and outs of fluid balance in the acutely ill patient. British Journal of Nursing, 24(1). doi: 10.12968/bjon.2015.24.1.14 Mßllerova, H., Chigbo, C., Hagan, G. W., Woodhead, M. A., Miravitlles, M., Davis, K. J., & Wedzicha, J. A. (2012). The natural history of community-acquired pneumonia in COPD patients: a population database analysis. Respiratory medicine, 106(8), 1124-1133. doi: http://doi.org/10.1016/j.rmed.2012.04.008 Ramos, F. L., Krahnke, J. S., & Kim, V. (2014). Clinical issues of mucus accumulation in COPD. Int J Chron Obstruct Pulmon Dis, 9, 139-150. doi: http://dx.doi.org/10.2147/COPD.S38938 Stephenson, A., Seitz, D., Bell, C. M., Gruneir, A., Gershon, A. S., Austin, P. C., ... & Gill, S. S. (2011). Inhaled anticholinergic drug therapy and the risk of acute urinary retention in chronic obstructive pulmonary disease: a population-based study. Archives of internal medicine, 171(10), 914-920. doi: 10.1001/archinternmed.2011.170 Sun, Y., Zheng, F., Li, Y., Wu, R., Liu, Y., Liu, M., ... & Gao, K. (2013). Correlation between lower gastrointestinal tract symptoms and quality of life in patients with stable chronic obstructive pulmonary disease. Journal of Traditional Chinese Medicine, 33(5), 608-614. doi: https://doi.org/10.1016/S0254-6272(14)60029-7 Tiziani, A. P. (2013). Havard's nursing guide to drugs (9th ed.). Elsevier Health Sciences. Volpato, E., Banfi, P., Rogers, S. M., & Pagnini, F. (2015). Relaxation techniques for people with chronic obstructive pulmonary disease: A systematic review and a meta-analysis. EvidenceBased Complementary and Alternative Medicine, 2015. doi: http://dx.doi.org/10.1155/2015/628365
Zarowitz, B. J., & O’Shea, T. (2012). Chronic obstructive pulmonary disease: prevalence, characteristics, and pharmacologic treatment in nursing home residents with cognitive impairment. Journal of Managed Care Pharmacy, 18(8), 598-606. doi: http://dx.doi.org/10.18553/jmcp.2012.18.8.598 There is plenty of information about gas exchange in COPD- the umbrella term Collapsed airways causing oxygen to become trapped distally with less oxygen available for diffusion across alveoli. Collapsed and damaged alveoli impairing the diffusion of carbon dioxide from the blood. Cite all authors in the first instance, then et al in subsequent citations Indicators are the measure of whether the goal has been achieved. Indicators need to include objective and, where appropriate subjective indicators and should be short/succinct specific statements. Goals should be short succinct statements of what you want to achieve, and be directly related to the problem. They should also be SMART – specific, measurable, attainable, relevant, timelimited. Most importantly they need to reflect the nursing problem. The nurse would make an emergency call, stay with Neville and remove the oxygen if it was still on. Reasons for the actions would be that oxygen will worsen the hypercapnia/hypoxia, and Neville should not be left unattended while he is confused and deteriorating while awaiting urgent medical attention.