Question

A 28 years old man who was exposed to weed killer in the basement of his apartment 3 weeks ago now came to a hospital complaining of having rashes, and experiencing shortness of breath, chest tightness, and coughing heavily. He is self employed, work seven days a week. He came because he had not been able to go to his primary clinic because of Covid-19. He does not have medical history that linked to what he is experiencing now. Because he works seven days a week on a homemade weed killer recipe that he made for living, he never thought of any side effect that could occur. The understanding of his work means so much to him.

After his checkup, The nurse followed up with him. He learned that he had asthma. The nurse warned him that he could be at very high risk of having complex issues of developing other illnesses if not treated on time. The nurse referred him back to his primary clinic to do a follow-up appointments to do more testing and offer some education on exercise that could lead to a healthier life.

I created this case scenario for practice. And need help developing (a) assessment (b) analyses (c) planning (d) implementation (e) Evaluation. I want to compare note and know my strength or weakness.

I'm developing a nursing care plan for this client.

Assessement: subjective and objective data collected

Analysis: nursing diagnoses( actual, potential or at risk, and teaching).

Planning: goal/outcome for each of the nursing diagnosis written in a SMART format.

Implementation: nursing actions for the achievement of each goal.

Evaluation: evaluate each goal/outcome(met, partially met, or not met)

Answer 1

Assessment	nursing diagnosis	goal	implementation	evaluation
Subjective data: Patient says that he is having difficulty in breathing, cough Objective data: On observation the patient looks fatigue and decrease the SpO2 level.	Ineffective breathing pattern related to swelling or spasm of bronchial due to inhaled allergens as evidence by difficulty in breathing and coughing	To maintain normal breathing pattern by decrease exposure to the allergens, no symptoms of breathing difficulty and cough	- Assess the condition of the patient - Check the patient;s oxygen level - provide in Fowler position to reduce difficulty in breathing. -Administer oxygen as per advice by the consult doctor. - Administer antihistamine drug to reduce the allergen reaction as per advice by the consult doctor. - Advice the patient to prevent exposing to the allergens.	patient maintained normal breathing pattern as evidence by decrease exposure to the allergens and no symptoms of breathing difficulty and cough
Subjective data: Patient says that he is not able to do daily activities proper due to shortness of breath on exertion Objective data on observation, patient look dull and not doing the daily activities properly	Activities intolerance related to shortness of breath and fatigue on exertion	To perform normal daily activities by decreasing the fatigue and no shortness of breath	- Assess the condition of the patient - monitor the oxygen level continuously - Provide Fowler's position and administered oxygen - Encourage to stop doing heavy work instead advice to perform less heavy work or activities only - provide the psychological support to the patient	-patient able to performed normal activities with absence of fatigue and no shortness of breath.
Subjective data patient says that he do not have much idea about the new disease condition that he is suffering now. Objective data On observation, the patient looks confuse about the treatment process	Deficient knowledge related to lack of source of information	patient will verbalize the knowledge and skills to be follow to overcome the disease condition.	- Assess the knowledge level of the patient - Explain the process of disease condition, signs and symptoms, treatment, prognosis of the condition. - provide booklet regarding the asthma, so that he can also refer at home - Explain the preventive measure like avoid from the allergens and use of mask whenever going outside the house. - Explain the breathing exercise that can be performed by the patient	Patient verbalized the increase in knowledge and skills to be followed to overcome the disease condition.
Objective date On observation, patient is delayed in taking the treatment	Risk for complication related to delayed in taking treatment.	patient will free from complication	- Assess for any sign of developing the complication. - check whether the patient is taking the treatment on time on not. - Educate the important of early treatment to prevent from the complication. - Counsel the patient regarding the problem for delayed in the treatment. - provide the psychological support. -encourage the family members also to involve in the treatment process.	patient is remained free from the risk of developing complication.