Question

Nursing Care Plan ) Case Study Linda Shaw is a 56-year-old female who was brought to the hospital by EMS on December 23, 2019. She presented to the emergency department with complaints of shortness of breath. She has had a productive cough for 3 days with a fever. She is admitted to the hospital with pneumonia and septicemia. She has a history of cellulitis, iron deficiency, high cholesterol and hypertension. She has an allergy to penicillin and vancomycin. She is taking ramipril 10mg daily, atorvastatin 20 mg daily and iron replacement daily. Since her arrival to hospital she has been on IV ceftriaxone 1gm q24 hours. She has been admitted for 2 days on the medicine unit that you are working on. Upon your assessment of the patient you notice she is short of breath during the interview. She can get no more than two words out before having to stop talking and rest. She is on wall oxygen at 2L via nasal prongs. You use your stethoscope to auscultate her chest and note decreased breath sounds to the LLL. You are aware that she has a left-sided pneumonia. You ask her to sit up in the bed and notice that she becomes increasingly short of breath with bed mobilization. Her respiratory rate is 24/min with evidence of accessory muscle use (abdominal breathing). You assess her oxygen saturation to be 92% on 2L of oxygen via nasal prongs. When asked if she has any pain the patient states “I have a heavy feeling in my chest”. You ask her what makes this pain worse, Linda states “The pain is worse when I am coughing”. You ask Linda when she first noticed the pain, “I first noticed the pain at 5am today”. Linda mentions that the pain in her chest seems to move into her throat. You ask Linda to describe the pain in her throat, “it is a scratchy pain”. Linda states that since changing her position on the bed she feels less pain. Linda states “before you asked me to move up in the bed my pain was 7/10 but since moving it is now 2/10 and mostly gone from my throat”. You assess Linda’s heart rate to be elevated (99 beats/min). You auscultate her apical pulse to match that finding. You note that her pulse is regular. You assess her blood pressure to be 111/80. You compare that to the blood pressure that the previous nurse had obtained overnight. Her pressure overnight was 118/79. You recognize that her blood pressure is lower than normal and ask her if she is dizzy or lightheaded, she tells you that she is not. Linda is alert and oriented and answering questions appropriately with no evidence of confusion. Upon assessment you note her pupils are equal and reactive bilaterally. Linda explains to you that she is feeling “unwell and tired”. She expresses frustration with her inability to sleep due to noise in the hallway at night. She tells you that she overheard the nurses talking all night long about baking Christmas cookies and it made her sad because she may not be home for Christmas. While Linda is talking to you about her inability to sleep, you notice that her oxygen saturation remains 92% despite her obvious shortness of breath when talking. Also, while she is talking to you, you take a look at her skin tone and note a normal skin colour and normal skin temperature. She does have dried blood at the site of her IV and the dressing is not intact. You assess her temperature to be elevated at 39 degrees Celsius. Linda also expresses frustration to you about being constipated, “I think I need some bran flakes. I haven’t had a bowel movement in 2 days”. Her abdomen does appear distended. You palpate all four of her abdominal quadrants and note they are soft and appear to be non-tender. You auscultate for bowel sounds and note that they are active in all quadrants. You ask Linda if she is passing gas, “you betcha” she replies. She tells you that before coming to the hospital she was 135lbs and that she believes she has lost weight. You ask her why she thinks this, “I haven’t eaten well since arriving to this hospital. I have no appetite and it seems to take a lot of effort to eat”. She seems to be moving her legs in bed frequently while you are interviewing her. You ask Linda, “Do you have pain in your legs?”. Linda explains that she does not have pain but rather wants to keep moving them so that she doesn’t “stiffen up”. Linda goes on to explain that she has had soreness and morning stiffness every morning for the last several years and her family doctor is investigating for arthritis. She denies requiring any mobility aids currently and denies any history of falls. You notice that Linda has a foley catheter insitu. There is 400cc of straw colour urine in the foley collection bag. You ask her why she has a catheter in. Linda states “the nurses put this catheter in while I was in the emergency department, they needed a urine specimen. Truthfully, I would like it out so that I can try to pee on my own”. Before terminating the interview, you hand Linda her cosmetic bag that she requested. She tears up and states, “I am not feeling much like putting make-up on. I fear that I will never get better. I seem to be wasting away in this bed. I am on my own with two kids in university so all that I can think about is who is going to work to pay for what they need. I need to get out of here!”. LAB VALUES AND DIAGNOSTIC TESTS FOR CASE STUDY #2 You can use the values below to add to the case study provided. If you have already developed the case study using your own lab values that is also acceptable. The idea is to explore the data and learn how to collect it in a comprehensive format along with identifying the priority nursing problem. WBC-16.2 Hgb-123 Plt-361 Na+-134 k-3.3 Cr-69 Glucose-6.2 CXR shows consolidation to left lower lung.

1-Assesment data collection/ demographics.

2-Clustring of data

3-identfying 1 priority rank 1-4

Answer 1

1-Assesment data collection/ demographics.

Answer 1:

Assesment

Assessment is a process by which the nurse collects the objective and the subjective patient data, organises the data into data clusters, validates it, analyses it and documents it to come to a nursing diagnosis and form a patient care plan

The different types of assessments are the initial assessment ,the emergency assessment, the problem focussed assessment and the time lapse assessment.

A comprehensive nursing assessment includes physical assessment , physiological assessment psychological assessment ,social and spiritual assessment of the patient thereby acheiving holistic patient assessment by the nurse.

The assessment findings for the above patient are described below

1.physical asssesment:

Vital signs:

Temperature 39 degrees celsius(febrile), pulse 99/min(tachycardia),RR=24/min,(tachypnea)blood pressure 111/80mmHg

General examination:

The patient is alert and oriented and answering questions appropriately with no evidence of confusion. She has shortness of breath during the interview.

Respiratory system

RR=24/min,(tachypnea).Patient has shortness of breath while talking in the interview.

There is use of accessory muscles of respiration(abdominal breathing) and patient complains of chest pain.

Absent breath sounds in left lower zone saturation on chest auscultation are noted.

The oxygen saturation is 92% on supplemental oxygen by nasal prongs..

The chest pain score on coughing decreases from 7/10 to 2/10 on moving up in bed and breathing when advised by the nurse.

CNS:The patient is alert and oriented ,no nervous deficit noted.Her pupils are equal and reactive

Abdominal system:Abdomen is softer to palpation with the normal bowel sounds.

Genitourinary assessment:the patient is 400cc of straw colour urine in the foley collection bag.

2.physiological assessment:

a]The physiological assessment of the patient reveals that patient has a ineffective airway clearance due to her productive cough and infection in the lungs as the breath sounds are decreased in the left lower lungs and patient has chest pain while breathing and coughing.

b]Patient needs support of her basic physiological needs (maslow's hierarchy--physiological needs level]with need of support for her airway, breathing and circulation.

.c]Also, the patient has had poor appetite and is not eating much .She needs nutritional support. Patient has had constipation and needs help with her bowel movement.

d]Patient has experienced acute sleep deprivation and needs help to sleep and rest.

3.psychological assessment :

Patient is anxious and fearful,She demonstrates ineffective coping and anxiety.She.fears that she will never get better. and seem to be wasting away in this bed. She is anxious as she is on her own with two kids in university so all that she can think about is who is going to work to pay for what they need.She is sad because she may not be home for Christmas.

4. social assessment:

Patient seems to be having poor social and family support system with two kids whose entire responsibility is on her. She seems to be the only earning member in the family.She is on her own with two kids in university so all that she can think about is who is going to work to pay for what they need.

5.spiritual assessment:

Patient wishes to be home for christmas.She is sad because she may not be home for Christmas and seems to be spiritually inclined.

data collection/ demographics.

Demographic data:

gender:female

age:56year old

marital status:married with two kids,spouse details unavailable.

race,ethnicity:details unavailable

employment status:employed and earning,currently on leave due to  sickness

Admitting Medical diagnosis:pneumonia and septicemia.

objective data:

The patient is alert and oriented and answering questions appropriately with no evidence of confusion.

The pupils are equal and reactive

Temperature 39 degrees celsius,(febrile) pulse 99/min,RR=24/min (tachypnea)Use of accessory muscles of respiration(abdominal breathing)

blood pressure 111/80mmHg

Absent breath sounds in left lower zone of lungs on auscultation.

oxygen saturation is 92% on supplemental oxygen with nasal prongs.

The chest Pain(on coughing) score decreases from 7/10 to 2/10 on moving up in bed and breathing

CXR shows consolidation to left lower lung.

WBC-16.2-leukocytosis,infection.

Abdomen is softer to palpitation with the normal breath sounds.

There is 400cc of straw colour urine in the foley collection bag.

Subjective data.

1.Patient has had a productive cough with fever for 3 days and shortness of breath

2.she has a history of cellulitis, iron deficiency, high cholesterol and hypertension.

3. She has an allergy to penicillin and vancomycin.

4.She is taking ramipril 10mg daily, atorvastatin 20 mg daily and iron replacement daily.

5.Patient has shortness of breath during the interview with the nurse.

6.She has a heavy feeling in her chest and the  pain worse on coughing.

7.She expresses frustration with her inability to sleep due to noise in the hallway at night.

8.She is sad because she may not be home for Christmas

9.she has has no appetite and seems to take a lot of effort to eat.She has not had a bowel movement in past two days.

10.She.fears that she will never get better.and seems to be wasting away in this bed. She is anxious as she is on her own with two kids in university so all that she can think about is who is going to work to pay for what they need.

Answer 2:

Clustering of data is a process wherein the nurse collects patient data ,both objective and subjective data and groups it so as to identify the problem and frame the nursing diagnosis.

Once the data cluster has identified the problem ,the nurse must identify the patient's strengths alongside with the problems and form a nursing care plan to address the patient's problems and motivate the patient.

The clustering of data ,both objective and subjective as identified from the above patient towards the priority nursing diagnosis is listed below. The clustering of this relevant data subjective and objective data helps to arrive at a nursing diagnosis and form a nursing care planfor her.

Here the patients subjective data of  fever,productive cough with sputum ,shortness of breath and chest pain has been clustered with the findings of elevated temperature ,tachycardia, tachypnea and absent breath sounds in left lower zone of lungs in order to to come to the nursing diagnosis of ineffective Airway clearance( physiological problem the patient is facing on account of pneumonia) and form the nursing care plan,

The related nursing priority clustered data identified from the above patient is tabulated below

Subjective data	data cluster interpretation and nursing diagnosis	objective data
Patient has a history of a productive cough, fever and shortness of breath. The patient has chest  (heaviness)pain while breathing and coughing	Ineffective Airway clearance	Temperature 39 degrees celsius, pulse 99/min,RR=24/min,blood pressure 111/80mmHg Use of accessory muscles of respiration(abdominal breathing) Absent breath sounds in left lower zone ,oxygen saturation 92% on supplemental oxygen. chest pain score decreases from 7/10 to 2/10 on moving up in bed and breathing(suggesting pleuritic pain) CXR shows consolidation to left lower lung. WBC-16.2-leukocytosis,infection.

3-identfying 1 priority rank 1-4

answer3:

The patient has a history of a productive cough, fever and shortness of breath.The nursing priority in this patient in the order of rank 1 to 4 are

1. Maintain a patent Airway and ensure your adequate blood oxygenation by assisting patient movement and coughing.

2. Assist patient breathing and effective coughing and control infection by admitting IV antibiotics

3. Maintain adequate circulation, patient hydration to maintain adequate blood pressure and to decrease the viscosity and thickness of the respiratory secretions and help inn their expectoration.

4.Patient education and teaching,Allay the patient's anxiety and promote effective patient coping.Patient is anxious and fearful and needs counselling for effective coping.