Sample Nursing Care Plan

Nursing Care Plan               The patient is Norm Gallagher, a 72 year old man who has been admitted for dyspnea or shortness of breath. Norm Gallagher reported that he has been coughing for the past week and his coughing has accompanied sputum discharge. His past medical history includes emphysema and chronic bronchitis. He used to smoke but has stopped since a year ago for economical reasons as well as it is also bad for his asthma. His bowel movements have also been irregular since his admission. He also reported that he is feeling depressed and fearful about the future. Further examination revealed that he has crackles in his left lower lobe with diffuse expiratory wheezing throughout his chest. Chest percussion also revealed his left lower lobe to be dull.   Needs / Problems Goals Interventions Evaluation Dyspnea or shortness of breath Use the visual analog scale (VAS) to make an objective assessment of dyspnea. The VAS is a 100-mm vertical line with end points of 0 and 10. zero is equated with no dyspnea and 10 is equated with the worst brethlessness the client has experienced (Potter & Perry, 2004) Dyspnea is difficult to quantify and to treat (Potter & Perry, 2004). Interventions need to be individualized for each patient, and more than one therapy is usually implemented. The underlying process that causes or worsens dyspnea must be treated and stabilized initially. Three additional therapies have to be implemented: pharmacological measures, physical techniques, and psychosocial techniques are then implemented. Evaluation of how nursing interventions in dyspnea is usually done by evaluating the underlying cause of dyspnea. Coughing up green and yellow sputum The nurse should determine if the cough is a manifestation of any underlying diseases. In addition, other diagnostic tests must be performed. Interventions can be geared towards curing the underlying cause such as chronic bronchitis. A cough is difficult to evaluate, and almost everyone has periods of coughing. Irregular bowel movement The client has only defecated once since being admitted for four days. The client has to resume his regular bowel movements which is every two days. Fluid intake has to be encouraged, and this should include appropriate fluids, fruit juice, and water. Activity within the limits of client’s mobility should also be encouraged. Laxative and stool softeners can be provided as ordered. Privacy is also important. The client should be asked for any increased activity. The client has to state that his activity pattern has changed therefore there is an achievement of outcome. The client’s subsequent stool should be observed for characteristics such as consistency and color. Bowel movement should now be every 24 to 48 hours. Abdomen should be soft and nondistended. Crackles in the left lower lobe of the lung with diffuse expiratory wheezing The nurse has to identify what is the underlying cause of the crackles and wheezing that is revealed in the patient’s exams. Since the generation of crackles depends more on lung volume changes than on airflow, patients should be advised to take slow and deep breaths in order to minimize flow turbulence and thus reduce the intensity of normal breath sounds (Pasterkamp, 2001). Wheezing in Norm Gallagher could just be normal response of his asthma and therefore interventions have to be geared towards his asthma. Evaluation of nursing interventions on crackles and wheezes should be related to the evaluation of the underlying cause of such clinical manifestations. Consolidation in left lower lung  The healthcare team responsible for the care of Norm Gallagher should examine the underlying cause of the consolidated lung. Nursing interventions should be geared towards treatment of the underlying cause, like pneumonia. The participation of other healthcare professionals is usually needed, like the diagnosis of a doctor. Conventional evaluation of the lungs is based on tests of lung volume, capacities and breathing of the patient, among others.               Dyspnea means mental anguish associated with an inability to ventilate enough to satisfy the demand for air (Guyton & Hall, 2000). It is a clinical sign of hypoxia and manifests as breathlessness or shortness of breath. It is the subjective sensation of difficult or uncomfortable breathing. A common synonym for it is air hunger. Dyspnea is shortness of breath associated with exercise or excitement, but in some clients dyspnea may be present without any relation to activity or exercise. Dyspnea is associated with many conditions, such as pulmonary diseases, cardiovascular diseases, neuromuscular conditions, and anemia (Potter & Perry, 2004). Environmental factors such as pollution, cold air, and smoking, may also cause or worsen dyspnea. In the case of Norm Gallagher, his dyspnea is probably related to his problem of the lung.             The rationale behind performing VAS for the patient is that dyspnea is subjective and performing VAS could objectively confirm if the patient is indeed experiencing dyspnea or not. Studies have validated the use of VAS to evaluate a client’s dyspnea in the clinical setting (Potter & Perry, 2004). The nurse can evaluate the effectiveness of nursing interventions by monitoring the client’s assessment of their dyspnea.             In the interventions for dyspnea, pharmacological agents may include bronchodilators, steroids, mucolytics, and low-dose antianxiety medications. Physical techniques, such as cardiopulmonary reconditioning through exercise, breathing techniques, and cough control, can help to reduce dyspnea. Relaxation techniques, biofeedback, and meditation are psychosocial measures that can lessen the sensation of dyspnea (Potter & Perry, 2004).             Cough is a sudden, audible expulsion of air from the lungs. Coughing is a protective reflex to clear the trachea, bronchi, and lungs of irritants and secretions. A cough is difficult to evaluate, and almost everyone has periods of coughing. Once the nurse determines that the client has a cough, it must be identified as productive or non-productive and its frequency must be assessed. In Norm Gallagher’s case, his cough is a productive one as it results in sputum production.             A productive cough results in sputum production, material coughed up from the lungs that may be swallowed or expectorated (Potter & Perry, 2004). Sputum contains mucus, cellular debris, and microorganisms, and it may contain pus or blood. It is the duty of the nurse to collect data about the type and quantity of sputum.             The rationale behind the nursing interventions in bowel elimination alterations of Norm Gallagher are pointed out in the succeeding sentences. Adequate fluid intake is necessary to prevent hard and dry stool. Activity including minimal ones such as leg lifts can increase peristalsis. The use of laxative and other medications can soften stool and prevent straining. Lastly, clients should feel relaxed when moving their bowels (Potter & Perry, 2004).             Auscultation of lung sounds involves listening for movement of air throughout all lung fields: anterior, posterior, and lateral. Adventitious or abnormal breath sounds occur with collapse of a lung segment, fluid in a lung segment, or narrowing or obstruction of an airway. Auscultation also evaluates the client’s response to interventions for improving Norm Gallagher’s response to interventions for improving his respiratory status (Potter & Perry, 2004).             Crackles are most commonly heard in dependent lobes: right and left lung bases. The cause is random, sudden reinflation of groups of alveoli and disruptive passage of air. Crackles (rales) are useful indicators of cardiorespiratory disease. The timing, pitch, and waveform of crackles reflect different pathophysiology in diseases, such as pneumonia, bronchiectasis, asbestosis, sarcoidosis, fibrosing alveolitis, cystic fibrosis, and pulmonary congestion due to cardiac failure (Pasterkamp, 2001). Wheezes on the other hand can be heard all over lung fields. The cause of this is high-velocity airflow through severely narrowed bronchus. They are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration. It is usually louder during expiration (Potter & Perry, 2004). Wheezing is a common clinical finding in patients with asthma and chronic obstructive pulmonary disease (COPD) during episodes of severe airway obstruction, and can also be heard in normal subjects during forced expiratory maneuvers; however, the properties of wheezing are difficult to perceive and quantify during auscultation (Morera, 2002). Chest percussion of Norm Gallagher revealed that his left lower lobe is dull. A dull or flat sound may suggest atelectasis, pleural effusion, pneumothorax or asthma (Potter & Perry, 2004).             The nurse should also take into account that Norm Gallagher is already 72 years old. The chest is normally more resonant in the child than in the adult. Breath sounds are also much louder in children because of the thinness of the chest wall. The normal assessment finding in the pulmonary system of an aging individual is as follows: The pathophysiological changes include (1) decreased chest wall compliance and loss of elastic recoil, (2) decreased respiratory muscle mass/strength, (3) increased ventilation/perfusion mismatch, (4) decreased alveolar surface area, (5) decreased carbon dioxide diffusion capacity, (6) decreased responsiveness of central and peripheral chemoreceptors to hypoxemia and hypercapnia, (7) decreased number of cilia, (8) decreased IgA production and humoral and cellular immunity, (9) decreased respiratory drive, and (10) decreased tone of upper airway muscles (Potter & Perry, 2004).             Key clinical findings in an aging pulmonary system includes (1) prolonged exhalation phase, (2) decreased vital capacity, (3) decreased PaO2, (4) decreased cardiac output, (5) slightly increased PaCO2, (6) increased respiratory rate, (7) decreased tidal volume, (8) decreased airway clearance, (9) diminished cough reflex, (10) increased risk of aspiration and infection, (11) increased risk of arterial oxygen desaturation, and (12) snoring, obstructive sleep apnea (Potter & Perry, 2004).             Upon physical examination of Norm Gallagher, it revealed that his arterial blood gases are at pH 7.36, the PaO2 is at 55 mmHg, and the PaCO2 is at 65 mmHg. PaCO2 is the partial pressure of carbon dioxide in the arterial blood and PaO2 is the partial pressure of oxygen in the arterial blood. Unlike liquids, gases expand to fill the volume available to them, and the volume occupied by a given number of gas molecules at a given temperature is ideally the same regardless of the composition of gas. This is what is called as the partial pressure. The normal values for PaCO2 andPaO2 are 40 mmHg and 100 mmHg respectively (Ganong, 2001).             The past medical history of Norm Gallagher showed that he has emphysema and chronic bronchitis. The term pulmonary emphysema literally means excess air in the lungs. However, chronic pulmonary emphysema is a complex obstructive and destructive process of the lungs that is in most instances a consequence of long-term smoking (Guyton & Hall, 2000). Chronic bronchitis is the chronic inflammation of the bronchi which leads to thickening of mucosa and decreased bronchial diameter (Marieb, 2004). Clients with chronic bronchitis generally produce sputum all day (Kozier & Erb, 2004). This is a result of the dependent accumulation of sputum in the airways and is associated with reduced mobility.             Consolidation of the lungs – whole lobes or even the whole lung – is usually a manifestation of pneumonia. Large areas of lungs become consolidated which means that they are filled with fluid and cellular debris (Guyton and Hall, 2000). All interventions and evaluation of treatments for Norm Gallagher has to take into account the underlying causes of his medical manifestations like crackles and wheezing.       REFERENCES   Ganong, W. 2001, Review of Medical Physiology 20th Edition. McGraw-Hill. Guyton, A. and Hall, J. 2000, Textbook of Medical Physiology 10th Edition. Harcourt Asia Pte Ltd. Kozier, B. and Erb, G. 2004, Fundamentals of Nursing: Concepts, Process, and Practice 7th Edition. Pearson Education Inc. Marieb, E. 2004, Essentials of Human Anatomy and Physiology 7th Edition. Pearson Education Inc. Morera, J. 2002, Detection of Wheezing During Maximal Forced Exhalation in Patients with Obstructed Airways, Chest. Pasterkamp, H. 2001, Auditory Detection of Simulated Crackles in Breath Sounds, Chest. Potter, P. and Perry, A. 2004, Fundamentals of Nursing. Mosby. Â

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