Patient Information/Assessment Data (A):Subjective: “Mrs. Rollings”Patient is apprehensive upon arrival as she has one daughter living in the area who is physically disabled and reliant on Mrs. Rollings for assistance with daily cares. Mrs. Rollings is also concerned about how she will pay for what Medicare does not cover with this hospital stay. Patient states she has been experiencing headaches, dizziness, a non-productive cough, chest pain of an 8 out of 10 with coughing, and shortness of breath that has worsened over the past 2 days.Objective: 82 year old Caucasian FemaleVITALS: HR: 99; Temp: 101.0 F; BP: 195/80; SpO2: 94% on room air; RR: 26. ASSESSMENT: History of Hypertension, COPD. Use of accessory muscles to breathe, adventitious breath sounds (diminished and wheezes) with auscultation. LABS: WBC: 9,000; Hgb: 18; Hct: 56; Platelet count: 256; Na:138 mEq/dL; K: 5.3 mEq/dL. PA and Lateral Chest X-ray demonstrates changes consistent with chronic emphysema and probable pneumonia. OTHER: Widowed. Cares for adult dependent daughter at home.2723515-64135004714875-63500704850-349250Nursing Problem/Diagnosis (D) Priority 1:Ineffective breathing pattern related to exasperation of COPD and respiratory illness (PA and Lateral Chest X-ray demonstrates changes consistent with chronic emphysema and probable pneumonia) as evidenced by dyspnea, tachypnea (RR of 26), use of accessory muscles to breathe, and adventitious breath sounds (diminished and wheezes) heard upon auscultation (Lippincott Advisor, 2019a).SMART Outcome (P):The patient will maintain normal pulse oximetry readings (96% and up), will have between 12 and 20 respirations per minute, and will verbalize increased ease of respirations after 24 hours.Interventions (I)/RationaleNurse will educate patient on the importance of and how to cough and deep breathe. Patient will be taught how to use an incentive spirometer. Nursing will continue to assist and promote the use of the incentive spirometer / coughing / deep breathing hourly. (Hinkle & Cheever, 2018, p. 488).Nurse will put in a request for respiratory therapy to come administer Albuterol unit dose per nebulizer every 4 hours and PRN. Nurse will monitor for effects and monitor for if the patient needs the medication PRN and will place the patient bed at a 45 degree angle or greater, to best facilitate chest expansion (Karch, 2017, p. 513).Nurse will administer Solu-Medrol 125 mg IVP every 6 hours and will monitor for side effects such as vertigo, hypotension, and muscle weakness (Karch, 2017, p. 595). Nurse will assess for respiratory rate, depth, effort (use of accessory muscles to breathe) and observe results of pulse oximetry hourly, as patient is ordered to be on continuous pulse oximetry. Outcome Evaluation (E):After 24 hours: the patient maintained normal pulse oximetry readings (96% and up), will have between 12-20 respirations per minute), and verbalizes increased ease of respirations.After 24 hours: the patient maintains normal pulse oximetry readings (96% and above); maintains a regular rate of 12-20 per minute, rhythm, and no longer uses accessory muscles for inhalation / exhalation; the patient states she has increased ease of respirations.Nursing Problem/Diagnosis (D) Priority 2: Acute Pain related to coughing and exasperation of COPD / respiratory illness (PA and Lateral Chest X-ray demonstrates changes consistent with chronic emphysema and probable pneumonia) as evidenced by chest pain of an 8 out of 10 (Lippincott Advisor, 2019b).SMART Outcome (P):Patient will identify their pain rating on a numerical scale at a 3 out of 10 or lower 30 minutes after the administration of Morphine IVP PRN Q4 for moderate to severe pain. Patient is able to use the teach back method to state her understanding of the importance of notifying the nurse of pain before it becomes unbearable.Interventions (I)/RationaleNurse will administer Morphine 2 mg IVP every 4 hours as needed for moderate to severe pain. Nurse will continue to assess for side effects such as depressed respirations, nausea, vomiting. Morphine given via IVP has a peak of 20 minutes, and a duration of 4 to 5 hours. Nurse will continue to reassess patient’s pain using the numerical scale (Hinkle & Cheever, 2018, p. 237).Nurse will administer Norco 5/325 1 tablet PO every 4 hours for mild-moderate pain and will continue to assess for side effects such as nausea, vomiting, and constipation. The nurse will educate the patient on the importance of notifying the nurse about her before the pain before it becomes unbearable (Karch, 2017, p. 443).Nurse will educate the patient about the bedrest order and encourage patient to adhere to the order, placing the patient’s belongings within reach along with the call light. Nurse will continue to assess pain, position, and toilet needs every hour (Taylor, Lillis, Lynn, & LeMone, 2015, p. 1157).Outcome Evaluation (E):30 minutes after receiving morphine, the patient will identify their pain at a 3 out of 10 or less on the numerical pain scale. Patient states her understanding of the importance of notifying the nurse of pain before it becomes unbearable using the teach back method.Nursing Problem/Diagnosis (D) Priority 3:Anxiety related to threat of current status (her Medicare coverage, her physically disabled daughter who is dependent upon her for daily cares) as evidenced by elevated HR and BP, increased respirations, apprehension and concern about her Medicare and situation of being a caregiver (Lippincott Advisor, 2019c).SMART Outcome (P):After 48 hours:The patient will verbalize decreased anxiety.The patient will identify factors that promote anxiety and will identify a coping mechanism.Interventions (I)/RationaleNurse will explain the care plan, all tests, and procedures to the patient using clear, simple explanations prior to administration. Nurse will give patient time to think of and ask all questions and will answer questions in a calm manner, providing resources (handouts explaining procedures, etc) as needed (Hinkle & Cheever, 2018, p. 232).Nurse will encourage the patient to verbalize stressors and will educate the patient on the importance of coping strategies. The nurse will help the patient identify appropriate coping strategies that have worked in the past, and encourage the use of these strategies (Taylor et al., 2015, p. 1591).Nurse will make a referral to a social worker to help the patient access community resources to address her home life and even her situation with Medicare benefits and any extra expenses (Taylor et al., 2015, p. 502).Outcome Evaluation (E):After 24 hours:The patient identifies factors that cause her anxiety and is able to identify one effective coping behavior to manage her anxiety. The patient states she has decreased anxiety.ReferencesHinkle, J. L., & Cheever, K.H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Wolters Kluwer Health. Retrieved from https://coursepoint.vitalsource.com.Karch, A. M. (2017). Focus on Nursing Pharmacology (7th ed.). Philadelphia, PA: Wolters Kluwer Health. Retrieved from https://coursepoint.vitalsource.com.Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015). Fundamentals of nursing: The art and science of person-centered nursing care (8th ed.). Philadelphia, PA: Wolters Kluwer Health. Retrieved from https://coursepoint.vitalsource.com.Lippencott Advisor. (2019a). NANDA diagnosis care plans: Ineffective breathing pattern. Retrieved from https://advisor-edu.lww.com/lna/document.do?bid=8&did=715218.Lippencott Advisor. (2019b). NANDA diagnosis care plans: Acute pain. Retrieved from https://advisor- edu.lww.com/lna/document.do?bid=8&did=715134. Lippencott Advisor. (2019c). NANDA diagnosis care plans: Anxiety. Retrieved from https://advisor- edu.lww.com/lna/document.do?bid=8&did=715135.
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