INTRODUCTION
According to Nettina, 2014, “the nursing process is a deliberate, problem solving approach to meeting the health care and nursing needs of the patients. The process as a whole cyclical, with the steps interrelated, interdependent and recurrent”. “The first step is assessment which involves the systematic, continuous collection, validation and communication of client data. So the nurse must gather and examine data to obtain all facts that are needed to determine client’s health status”.(Lecture Notes, 2016).Diagnosis step involves judging the client clinically so that so that nurses are able to provide for a better choice regarding nursing mediation or intervention associated with client’s condition. Moving on, planning is another step which focuses on priorities of diagnosis that must be allocated and whilst sorting long term and short term goal, nurses must ensure that goals are detectable. In implementation step, it involves performing activities which will be provided to the client in order to grant the achievement of the outcome that is to be expected. The evaluation step requires observation of the client’s goals have been met .So if the goals are not met then nurse must re-start with her nursing process steps but if these goals were met then the nurse must discontinue with her care. Therefore, this assignment will further elaborate on the steps of nursing process with regards to the case scenario of Mrs. X.
ASSESSMENT
• Subjective Data
Bio Data
Name: Mrs. X
Age: 40 years
Sex: Female
Religion: Methodist
Ethnicity: I-taukei
Marital Status: Married
Occupation: School Teacher
Address: Damanu Street
Emergency Contact: 9904133/8810555
Chief Complain: The cough is very productive till today.
History of Present illness: Cough started when she had mild fever for three weeks ago.
Social History: Mrs. X drinks grog occasionally and smokes three rolls of cigarette a day.
Functional Health Problem: Mrs. X cannot mobilize to perform daily household activities. She is assisted by her aunt.
• Objective Data
Mrs. X wore warm clothes suited with her condition
Pale looking
Lethargic
Shortness of breath
Vital Signs
Took observations for Mrs. X and temperature increased (Hyperthermia) and she also had fast breathing rate (Tachypnea).
DIAGNOSIS
1. Ineffective Airway Clearance
2. Impaired physical Mobility
3. Ineffective Breathing Pattern
4. Acute Pain
5. Disturbed Sleeping Pattern
6. Activity Intolerance
7. Impaired Physical Mobility
8. Impaired Comfort
9. Risk for Infection
Expected Outcome:
1. Ineffective Breathing Pattern
To restore normal airway passage within a week.
2. Impaired Gas Exchange
To maintain normal gas exchange of normal range within a week.
3. Ineffective Breathing Pattern
To completely restore normal breathing patterns of client within three days.
4. Acute Pain
To promote pharmacological and non-pharmacological therapy within three weeks.
5. Disturbed Sleeping Pattern
To maintain adequate sleep and rest within three days.
6. Activity Intolerance
The client must be able to maintain activity level of capabilities within two weeks.
7. Impaired Physical Mobility
To restore the clients physical activity independently within two weeks.
8. Impaired Comfort
To promote psychological support and reassurance within two days.
9. Risk For Infection
To restore normal vital signs within two days and maintaining client’s health is free from infection within three weeks.
INTERVENTION
1. Ineffective Airway Clearance
Assess Mrs. X’s cough for effectiveness.
2. Impaired Gas Exchange
Assess respiration rate, breathing effort.
3. Ineffective Breathing Pattern
Assess client’s respiration rate.
4. Acute Pain
Assess client’s pain characteristics.
5. Disturbed Sleeping Pattern
Assist client to sit in semi-fowlers position.
6. Activity Intolerance
Assist in assigning priority activities to accommodate energy level.
7. Impaired Physical Mobility
Assess clients need for assistive devices such as wheelchair.
8. Impaired Comfort
Assist client in massage (non-pharmacological) therapy.
9. Risk For Infection
Assess client’s nutritional status such as weight.
EVALUATION
1) Ineffective Airway Clearance
• Client’s normal airway passage restored within a week.
2) Impaired Gas Exchange
• Gas exchange maintained to a normal range within four days.
3) Ineffective Breathing Pattern
• Clients breathing pattern restored within three days.
4) Acute Pain
• Pharmacological and non-pharmacological therapy promoted within three weeks.
5) Disturbed Sleep Pattern
• Normal sleep and rest pattern restored for client within three days.
6) Activity Intolerance
• Client is able to completely maintain activity level of capabilities within two weeks.
7) Impaired Physical Mobility
• Physical activity of client restored independently within two weeks.
8) Impaired Comfort
• Client’s psychological and reassurance support promoted within two days.
9) Risk For Infection
• Normal vital signs restored within two days and clients health free from infection within three weeks.
DIAGNOSIS
EXPECTED OUTCOME INTERVENTION EVALUATION
Ineffective Airway Clearance To restore normal airway passage within a week. Assess Mrs. X’s cough for effectiveness. Client’s normal airway passage restored within a week.
Impaired Gas Exchange
To maintain excellent gas exchange of normal range within a week. Assess respiration rate, breathing effort. Gas exchange maintained to a normal range within four days.
Ineffective Breathing Pattern To completely restore normal breathing patterns of client within three weeks. Assess client’s respiration rate. Clients breathing pattern restored within three days.
Acute Pain To promote pharmacological and
Non-pharmacological therapy within three weeks. Assess client’s pain characteristics. Pharmacological and non-pharmacological therapy promoted within three weeks.
Disturbed Sleeping Pattern To maintain adequate sleep and rest within three days. Assist client in a semi-fowlers position. Normal sleep and rest pattern restored for client within three days.
Activity Intolerance Client must be able to maintain activity level of capabilities within two weeks. Assist in assigning priority activities to accommodate energy level. Client able to completely maintain activity level of capabilities within two weeks.
Impaired Physical Mobility To restore clients physical activity independently within two weeks. Assess clients need for assistive devices such as wheelchair. Physical activity of client restored independently within two weeks.
Impaired Comfort To promote psychological support and reassurance within two days Assist client in massage (non-pharmacological) therapy. Client’s psychological support and reassurance support promoted within two days.
Risk For Infection To restore normal vital signs within two days and maintaining health is free from infection within three weeks. Assess nutritional status such as weight and vital signs. Normal vital signs restored within two days and clients health free from infection within three weeks.
INDEPENDENT AND COLLABORATIVE INTERVENTION
Ineffective Airway Clearance
Independent-Positioning bed to semi-fowlers position (head of bed at 45°).
Collaborative- Refer client to respiratory therapist and nebulizer treatment as indicated.
Impaired Gas Exchange
Independent- Monitor vital signs and be vigilant about changes.
Collaborative- Use pulse oximetry saturation to maintain pulse rate and oxygen saturation as indicated.
Ineffective Breathing Pattern
Independent- Monitor oxygen saturation and heart rate.
Collaborative- Refer to lab technician for sputum testing.
Acute Pain
Independent- Monitor client’s vital signs.
Collaborative- Assist with pain relief method as medicated.
Disturbed Sleep Pattern
Independent- Observe factors interfering normal pattern.
Collaborative- Administer passive exercise for easier sleep of client at night as organized by physiotherapist.
Activity Intolerance
Independent –Monitor client’s energy conservation technique such as frequently placing used items within easy reach.
Collaborative- Arrange for physical therapist for assessing use of ambulation aid to family members.
Impaired Physical Mobility
Independent- Monitor elimination status.
Collaborative- Set up a bowel program for client.
Impaired Comfort
Independent- Monitor vital signs and medication as Doctors order.
Collaborative- Refer client to Physiotherapist to assess clients physical condition.
Risk for Infection
Independent- Monitor signs of infection such as elevated temperature, color of respiratory secretion.
Collaborative- Administer the use of antibiotic drugs as ordered.
LONG TERM AND SHORT TERM GOAL
Short Term Goal
• To maintain excellent gas exchange of normal range within a week.
• To completely restore normal breathing patterns of client within three days.
• To maintain adequate sleep and rest within three days.
• To promote psychological support and reassurance within two days
• Client must restore normal vital signs within two days.
Long Term Goal
• To restore normal airway passage within a week.
• To promote pharmacological and non- pharmacological therapy within three weeks.
• Client must be able to maintain activity level of capabilities within two weeks.
• Maintain client’s health is free from infection within three weeks.
REFERENCE
• Doenges, E. M., Moorehouse. , F. M, & Murr, C. A. (2016) .Nursing Care Plan:
Individuality client care cross the life span (9th Ed.).Philadelphia: F. A. Davis.
• Drauna, U. (2016). Personal Communication. Sangam College of Nursing, Labasa. Fiji.
• Gulanick, M., & Myers, L. J. (2007). Nursing Care Plans: Nursing Diagnosis and
Intervention (6th Ed.). St. Louis, Missouri, USA: Elsevier.
• Nettina, M. S. (2014) Lippincott Manual of Nursing Practice (10th Ed.).Wolters Kluwer.