Nursing Care Plan

Nursing Care PlanSunday, May 20, 2012Nursing Care Plan Introduction“The nursing care plan is an essential part of patient care. It consolidates a patient's present diagnosis, physical assessment, history, and medical records into a clear plan of action. A care plan offers a holistic approach to patient care and continues to evolve until the patient is discharged” (Medi-Smart. com, 2012, p. 3). By creating nursing care plan, it “gives nurses a way to track patients' progress and provide appropriate treatment. Because nurses work with multiple patients per day, they rely on care plans to quickly access a patient's history, diagnosis, and treatment plan” (Medi-Smart. com, 2012, p. 1).In Mrs. Lee’s case, she is 80-year-old Asian-Canadian woman. She is admitted to the transition unit with difficulty breathing, heart diseases and malnutrition. As a student practical nurse, I should try my best to make a good care plan to deal with Lee’s problems. Therefore, in this care plan, due to my client’s situation, I will discuss about three diagnoses, assessment and interventions to help her deal with the health issues.Diagnoses1.Impaired spontaneous ventilation related to heart failure and heart overload as evidenceby slightly short of breath, pale, complaining of "unable to catch her breath", sitting upeither in an easy chair or in bed with three pillows supporting her back at home.2.Decreased cardiac output related to hypertension and heart diseases such as Coronaryartery disease and history myocardial infarction as evidence by heart rate is irregular, and her apical pulse is 128 beats per minute. Her right radial pulse is 110 beats per minute,and her left radial pulse is 112 beats per minute.3.Nutrition less than body requirement related to less food intake as evidence by lost 4kilogram in one month, electrolytes (potassium and sodium)imbalance and the lower lab value of Hgb and Hct.PrioritizationThe first prioritization is to treat patient’s respiratory problem (diagnosis 1). As it known to all, human bei ngs need oxygen to survive. In human body, “the trillions of cells in the body need a constant and generous amount of oxygen to carry out their vital functions. As they use that oxygen, they give off carbon dioxide as a waste product” (Nagel & Frey, 2007, p. 1). The respiratory system work with cardiovascular system to deliver oxygen into human body and get waste gases out. Therefore, “if breathing stops, however, a person becomes acutely aware of the fact. An individual can go days without food and water and hours without sleep, but only five or six minutes without air. Anything beyond that would be fatal” (Nagel & Frey, 2007, p. 1). According to scenario, Mrs. Lee is experiencing hard time to breathe. She has slightly shortness of breath; because of lack of oxygen, she is in pale and feel tired; she also has been complaining of "unable to catch her breath"; moreover, when Mrs. Lee is at home, she requires sitting up either in an easy chair or in bed with three pillows supporting her back to keep her breathing easily. More importantly, she has heart diseases. Thus, it is obvious that to obtain enough oxygen and control breathing rate should be implemented initially.The second prioritization is to deal with the decreased cardiac output. According to Nagel and Frey (2007), respiratory system needs cardiovascular system to work together to get air into and out human body (p. 1). Right now, Mrs. Lee’s heart rate is irregular, and her apical impulse is displaced down and to the left, covering two intercostals spaces. She feels tired, and there is apitting edema +2 on her both ankles. Additionally, her apical pulse is 128 beats per minute. Her right radial pulse is 110 beats per minute, and her left radial pulse is 112 beats per minute. Because of Mrs. Lee’s elderly age and experiencing heart diseases, if the decreased cardiac output does not be solved, she may develop chest pain, rapid breathing, decreased blood pressure and altered mental status ( Health Grades Inc., 2012). Some complications are fatal for her. As a result, after coping with her breathing problem, to manage her cardiac output problem should be considered next immediately.The third prioritization is to manage her diet. The nutrient problem is not much significant as former two problems. It will not to kill the patient immediately. Mrs. Lee lose appetite, she lost 4 kilogram within a month. In addition, according to the lab value, the value of electrolytes like potassium and sodium is little bit lower than normal range; the levels of Hgb, especially Hct are really low, which means patient does not have enough nutrients (A.D.A.M., Inc., 2010). To deal with her diet, I need to contact with the dietitian and nutritionist to make a food plan for her. Gain enough nutrient needs take time. Therefore, I put manage nutrient in to the last consideration.AssessmentDiagnosis 1Mrs. Lee, an 80-year-old Asian-Canadian woman, speaks broken English, so she needs her daughter to accompany with her. She has slightly shortness of breath during she talks. Though the observation, she is pale and has a slim and short figure. As her daughter mentioned, she complaint of tiredness and unable to catch her breath; moreover, when she is at home, she requires sitting up either in an easy chair or in bed with three pillows supporting her back.During physical assessment, I found her JVD is 6 cm and the heart is expanded, due to the displacement of apical impulse. Also, her heart sounds are irregular. When I aucultated her lung sounds, I heard crackles throughout the lung bases bilaterally up to the base of the scapula.In lab value, her Hgb and Hct values are low. She is diagnosed with coronary artery disease and hypertension. She had angioplasty and stent to right coronary artery in 2005 for treating myocardial infarction. The administered medication s are for treating hypertension, heart diseases, fluid retention and constipation.Interventions & rationalesDiagnosis 11.Administer oxygen to patient, start with 2 liters per minute, check oxygen saturationevery 15 minutes and monitor it; “p osition client by elevating head of bed; place in prone position” (Newfield et al, 2007, p. 176).Rationale: “Elevating the client’s head and helping client get out of bed while still on the ventilator is both physically—helps decrease risk of aspiration—and psychologicallybeneficial. Note: Use of prone position is thought to improve oxygenation in client with severe hypoxic respiratory failure” (Newfield et al, 2007, p. 176).2.Instruct coughing exercise and “Instruct in diaphragmatic deep breathing and pursed-lipbreathing” (Doenges, Moorhouse, & Murr, 2010, p. 308).Rationale: “p romotes lung expansion and slightly increases pressure in the airways,allowing them to remain open longer” (Doenges, Moorhouse, & Murr, 2010, p. 308).3.“Auscultate chest periodically, noting presence or absence and equality of breath sounds,adventitious breath sounds.” (Doenges, Moorhouse, & Murr, 2010, p. 176).Rationale: “p rovides information regarding airflow through the tracheobronchial tree and the presence or absence of fluid, mucous obstruction. Note: Frequent crackles or rhonchi that do not clear with coughing or suctioning may indicate developing complications,such as atelectasis, pneumonia, acute bronchospasm, and pulmonary edema” (Doenges, Moorhouse, & Murr, 2010, p. 176).ConclusionTo sum up, by doing nursing care plan for Mrs. Lee helps me learn a lot and know deeply about my patient’s condition. By doing assessment, I know my patient is 80 years old lady with Asian background. Due to language barrier, she needs her daughter accompany with her. She has difficulty of breathing, imbalanced nutrition, and progressive heart disease. During assessment, I found out she develops some signs and symptoms of heart failure, such as rapid and irregular heartbeat, tiredness, lack of appetite, swelling at the ankles and slightly shortness of breath. Throughout diagnoses, I analyzed what I knew from the assessment of Mrs. Lee, and then find out what the actual or potential health problems with her. Also, I decided the most important health problem that I need to consider initially. By doing the interventions, I did research and noticed the appropriate interventions for Mrs. Lee. Further, I knew why I need to do in this way.In real practice, appropriate care plan is really helpful. “Because m ultiple nurses will work with the same patient, the care plan needs to be specific enough for any nurse to be able to pick it up and effectively continue the care for the patient” (Medi-Smart. com, 2012, p. 2). Consequently, making a good care plan is not only convenient nurses to take care for patient, but also beneficial for clients get an adequate care.ReferencesHealth Grades Inc. (2012, Feburary 1). Symptoms of Decreased cardiac output . Retrieved May 19, 2012, from RD:/d/decreased_cardiac_output/symptoms.htmA.D.A.M., Inc. (2010, September 2). Hematocrit. Retrieved May 16, 2012, from MedlinePlus:/medlineplus/ency/article/003646.htmDoenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans Edition 8.Philadelphia: F.A. Davis Company.Medi-Smart. com. (2012). Nursing Care Plan Resources. Retrieved May 19, 2012, from Medi-Smart: /nursing-resources/careplanNagel, R., & Frey, R. (2007). The Respiratory System. From the Digestive System to the Skeleton. Betz Des Chenes, Editor. Online Edition. Farmington Hills, MI: UXL, 2007. Newfield, S., Hinz, M., Tilley, D., Sridaromont, K., & Maramba, P. (2007). Chapter 5: activity-exercise pattern. In , Cox's Clinical Applications of Nursing Diagnosis (pp. 269-419).Philadelphia, Pennsylvania: F.A. Davis.。