Question

Case Study: You are a nurse caring for a 26 year-old mother of three children who presents to the physician's office with tachypnea, productive cough of yellow sputum, hyperthermia, malaise, fatigue and insufficient fluid intake. You obtain the following information during your objective assessment: Vital signs are BP- 120/78, HR- 110, respirations 24/minute, temperature 100.4 orally and pulse oximeter of 90% on room air (RA). Upon auscultation, you note coarse rhonchi in bilateral posterior lobes. She complaints of pain of 8/10 in her anterior right side of her chest after coughing. 1) Describe the rationale for performing a comprehensive physical assessment on this patient. 2) Prioritize the symptoms to be assessed on this patient and explain which system would have the highest priority for this assessment and why? 3) List the appropriate subjective health history questions that could identify this patient's risk factors for her altered respiratory condition. 4) Describe the etiology of this patient's overall assessment. What do you think is the condition this patient is experiencing? 5) List 3 priority nursing diagnoses for this patient. Remember the need to prioritize diagnoses based on Maslow's hierarchy of needs, including ABC's, pain and VS. For each of these 3 nursing diagnoses, include one short-term and one long-term SMART goal and include 3 interventions with rationales to support these interventions.

Answer 1

1. Rationale for comprehensive physical assessment.

To determine the accuracy of various physical examination maneuvers in diagnosing the disease. Chest physical examination findings can be confirmed with other diagnostic studies.

2. Prioritize the symptoms to be assessed on this patient and explain which system would have the highest priority for this assessment and why?

* Hyperthermia

* Productive cough of yellow sputum

* Tachypnea

* Coarse ronchi breath sound

* Fatigue, Malaise

* Insufficient fluid intake

* Vital signs

Should give priority to respiratory system as because the client shows altered respiratory symptoms and the chest pain after coughing.

3. List the appropriate subjective health history questions that could identify this patient's risk factors for her altered respiratory condition.

* Do you smoke? Is yes, since how long do you smoke?

* What is your occupation? (To find out the occupational hazards)

* Do you have any other problem? (To find out any systemic disease)

* How long do you have these symptoms?

* Do you hospitalized before for a longer period? (To find out hospital acquired infection)

* Dietary pattern? (Poor nutrition may weaken immune system)

4) Describe the etiology of this patient's overall assessment. What do you think is the condition this patient is experiencing?

Weakened immune system

Infection due to Occupational hazards.

As per the client's symptom and the assessment, she us experiencing with Pneumonia.

5) List 3 priority nursing diagnoses for this patient. Remember the need to prioritize diagnoses based on Maslow's hierarchy of needs, including ABC's, pain and VS. For each of these 3 nursing diagnoses, include one short-term and one long-term SMART goal and include 3 interventions with rationales to support these interventions.

1. Ineffective airway clearance related to increased production of secretions and increased viscosity.

Short- term goal:

Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.

Long-term goal:

Patient will demonstrate increased air exchange.

Nursing interventions with rationale:

* Monitor respiratory patterns, including rate, depth, and effort.
A normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase.

* Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary. Do not do nasotracheal suctioning.
It is preferable for the client to cough up secretions.

* Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side at least every 2 hours.
Body movement helps mobilize secretions.

* Help client to deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles.
This technique can help increase sputum clearance and decrease cough spasms. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.

2. Impaired Gas Exchange related to inflammation of airway and smaltered oxygen delivery.

Short-term goal:

Patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.

Long-term goal:

Patient will maintain optimal gas exchange.

Nursing interventions with rationale:

* Observe color of skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral).

As oxygenation and perfusion become impaired, peripheral tissues become cyanotic.

* Maintain bedrest by planning activity and rest periods to minimize energy use. Encourage use of relaxation techniques and diversional activities.

Prevents over exhaustion and reduces oxygen demands to facilitate resolution of infection. Relaxation techniques helps conserve energy that can be used for effective breathing and coughing efforts.

* Elevate head and encourage frequent position changes, deep breathing, and effective coughing.

These measures promote maximum chest expansion, mobilize secretions and improve ventilation.

* Administer oxygen therapy by appropriate means: nasal prongs, mask, Venturi mask.

The purpose of oxygen therapy is to maintain PaO2 level. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance.

3. Acute pain related to inflammation of lung parenchyma.

Short-term goal:

Patient will verbalize relief/control of pain at level less than 3 to 4 using a rating scale of 0 to 10.

Long-term goal:

Patient will verbalize understanding of nonpharmacological interventions for pain relief.

Nursing interventions with rationale:

* Provide comfort measures: back rubs, position changes, quite music, massage. Encourage use of relaxation and/or breathing exercises.

Non-analgesic measures administered with a gentle touch can lessen discomfort and augment therapeutic effects of analgesics. Patient involvement in pain control measures promotes independence and enhances sense of well-being.

* Instruct and assist patient in chest splinting techniques during coughing episodes.

Aids in control of chest discomfort while enhancing the effectiveness of cough effort.

* Administer analgesics as prescribed. Encourage patient to take analgesics before discomfort becomes severe.

Medications allow for pain relief and the ability to deep breathe and cough. Analgesics help prevent peak periods of pain.