Student Name: XYZ 1

THE WILLIAM PATERSON UNIVERSITY OF NEW JERSEY

COLLEGE OF SCIENCE AND HEALTH
DEPARTMENT OF NURSING

NURSING CARE PLAN

Patient’s Initials: J.M. Date: 11/09/2010

Primary Diagnosis: Exacerbation of COPD, Dehydration Patient’s Age: 97 Room Number: 360

Incidence: In the United States, approximately 16.4 million people suffer from Chronic Obstructive Pulmonary disease, (COPD). According to the American Lung Association, COPD effects
approximately 14 million people suffer from chronic bronchitis, the seventh leading chronic condition in the United States. There are an estimated 1.9 million people suffering with emphysema. Of these,
55.5% are men and 44.5% are women. Between 1982 and 1995 emphysema increased in women by 14.8%, probably due to the increased rate of smoking among women. An estimated 50,000 to
100,000 people, primarily of northern European descent, have AAT deficiency emphysema. COPD is the fourth leading cause of death in the United States. In 1996, approximately 100,360 people died
as a result of COPD.
COPD is the 4th leading cause of death in the US. It causes serious long-term disability and early death. At this time there is no cure for COPD. More than 12
million people are known to have COPD and up to 24 million may have the disease due to some not even knowing it. The number of people dying from COPD is
growing. Deaths due to COPD in women are higher than in men. COPD is often not found until the disease is very advanced because people do not know the early
warning signs. Sometimes people think they are short of breath or less able to do the things they are used to doing because they are "just getting old". But shortness
of breath is never normal. The good news is that COPD can be found early and there is much that can be done to treat and help manage the disease.

COPD is a lung disease that over time makes it hard to breathe. COPD (short for Chronic Obstructive Pulmonary Disease) includes chronic bronchitis and emphysema. Obstruction in COPD means that the
flow of air in and out of the lungs is less than it should be. When that happens less oxygen gets into the body tissues and it becomes harder to get rid of carbon dioxide which is the waste gas. As the
disease gets worse, it is harder to remain active due to shortness of breath. Most importantly, COPD can be prevented and can be treated.

With chronic bronchitis the lining of the breathing tubes become swollen and produces a lot of mucus that gets coughed up. With emphysema the walls of the air sacs in the lung are broken down and the
air spaces get larger and air gets trapped. Some people have both chronic bronchitis and emphysema, so we now prefer to call the disease COPD.
Student Name: XYZ 2

Etiology: More than 90% of all lung cancers fall into four major histologic types: adenocarcinoma, large cell and squamous cell carcinoma, and small cell lung cancer. Small cell cancer grows

the most rapidly and is the most responsive to cytotoxic chemotherapy. (Monahan et. al, 2007, p.643) Lung cancer can affect other systems in the body when metastasized to structures such as

the brain, liver, kidneys, adrenal glands or skeleton. (Monahan et. al, 2007, p.646) For patients with non-small cell lung cancer the size of the tumor and degree of metastasis determines the

prognosis. As with other cancer, lung cancer is measured in stages. The two stages are limited and extensive. Limited stage indicates the tumor is confined while extensive indicates metastasis.

Metastatic tumors may follow malignancy anywhere in the body, including the colon and the kidneys, sites that are very common to metastasized lung cancer. (Monahan et. al, 2007, p. 643)

While the tumor may be discovered before reaching the stage of affecting other system, sometimes its location will not be evident until it is found only at autopsy. (Monahan et. al, 2007, p. 643)

Signs and Symptoms: Individual patient’s signs and symptoms vary and depend on several factors. One of these factors includes the location of the lesion in the lung. In approximately 10% of

cases, patients are asymptomatic and the cancer is identified on a routine chest x-ray film. (Monahan et. al, 2007, p.646) Of the symptoms that are evident, approximately 75% have a cough and

approximately 50% have hemoptysis. Shortness of breath and wheezes heard on auscultation are also common. If lesions have perforated into the pleural space, patients might also show signs of

pain on inspiration, friction rub, pleural effusion, edema of the face and neck, fatigue and clubbing of the fingers. (Monahan et. al, 2007, p.646) As the disease progresses other systems in the

body begin to break down and affect the overall health and weight of the individual.

Treatment: The collaborative care approaches to a patient suffering from lung cancer include surgical intervention, medications, and chemotherapy concurrently with radiotherapy. Surgical

interventions must be discussed with risk and benefits fully weighed. Patient’s age, pulmonary reserve, and presence of cardiovascular disease might increase the chance of post-op

complications. (Monahan et. al, 2007, p.648) Mortality and morbidity rate increases with age when performing a surgical intervention for cancer of the lung patients. Therefore ABG and PFTs

are used to measure pulmonary reserve to determine operability. If a decision is made to operate an exploratory thoracotomy confirms the diagnosis of lung or chest disease. (Monahan et. al,

2007, p.650) Afterwards the approach to the type of thoracic surgery that will be used is determined by the extent of metastasis and location of the cancer. Pneumonectomy, or removal of a

lung, or a lobectomy, a removal of one lobe, can be performed along with resections (removal of one or more segments) and decortication (removal of fibrous peel from the pleura). (Monahan et.

al, 2007, p.650) Aside from surgery, radiotherapy concurrently with chemotherapy is also used because it appears to improve survival rate for patients. However it also does increase the risk of

immune system suppression. Finally a group of medications that are cytotoxic can be used in lieu of chemotherapy to extend the survival time of patients. These drugs are a good candidate for
Student Name: XYZ 3

patients that have minimal weight loss, less extensive disease spread, and adequate functionality. (Monahan et. al, 2007, p.648) The approaches discussed, once again, have to take into

consideration the degree and severity of each patient before a treatment plan is administered.

Diagnostics: Confirmed diagnosis of lung cancer requires examination of the tumor. Specimens must be obtained through bronchoscopy, transthoracic needle biopsy, or surgery. Less invasive

procedures such as CT scan and MRI can help differentiate underlying mass from atelectasis or inflammation. A PET scan can aid in diagnosing metastatic sites if cancer is present. (Monahan

et. al, 2007, p.649) An invasive procedure such as a bronchoscopy yields a more definitive finding. Bronchoscopy is used to obtain tissue from the central tumor but can also brush and wash the

peripheral lesions. A transthoracic needle biopsy and surgery can be used to diagnose malignancies in peripheral lung nodules. Another type of diagnostic test is the cytologic analysis of sputum

that can be used to diagnose lung cancer. It is considered the safest and least expensive of the tests. Simple sputum is analyzed for bacteria and cancer cells to determine the presence of cancer.

(Monahan et. al, 2007, p.649)

Past and Concurrent Medical History

The patient is a 57 year old Caucasian female with a history of COPD. She smoked 1 pack a day for 38 years but claims to have had no significant medical problems. When asked if she

suffered from hypertension, diabetes, stroke, etc. the patient claims that aside from the seasonal cold and flu, she remained mostly healthy throughout her life. She was diagnosed with non-small

cell lung cancer in June of 2007 and has then only quit her smoking habit. The patient did admit that she did suffer from stage I hypertension but has since lowered her blood pressure without

any blood pressure medication. She had an open reduction internal fixation to treat a fractured femur in 2005. Her ongoing chemo and radiotherapy have not “affected her much” as she only

slightly lost weight. She also claims that the side effects of the treatment are minimal with only slight feeling of nausea and vomiting. Her history does include leukocytopenia and

thrombocytopenia which required the administration of Neupogin to increase her leukocytes. Her hematologic problems have been from the cancer as she indicates that she has not had problems

with her blood any other time in her life. The patient states that she has no heart problems aside from the hypertension previously mentioned but has now resolved, according to her, and denies

any history of drug use. Prior to her diagnosis of cancer she saw her doctor once a year and lived an “uneventful life”. The patient has also indicated that she drank alcohol for many years but

was for the most part social drinking. During her divorce however she indicated that she used alcohol as a means to cope. But after establishing a mutual understanding with her husband, had
Student Name: XYZ 4

decreased alcohol consumption to levels before she had gotten a divorce. The patient does not take OTC drugs or use herbal supplements according to her. She takes the occasional antacid for

stomach upset especially during her treatment phase. The dietician has instructed her to eat high calorie, high protein to bring her weight to optimal levels in order for her to fight off possible

infections. The patient was admitted to the hospital because of chest pain and shortness of breath. Following examination it was determined that she had pneumonia and sepsis, both treated with

antibiotics on an inpatient basis.

The initial goal of the medical care given to her on admission was to treat the infection in her lungs and prevent further spread of the infection in her body. The medications that are currently

in their treatment regimen are:

1. Zithromax 250mg PO daily – antibiotic: macrolide antibiotic (semisynthetic)

2. Casodex 50mg 1 TAB OD –

3. Flowmax 0.4mg 1 CAP OD

4. Flowvent 110 x2 Puffs BID

5. Prilosec 40 mg ER CAP OD –

6. Albuterol 2.5mg + Atrovent 0.5g Q4H while awake – respiratory drug therapy to decrease inflammation, dilate bronchioles, ease respiratory effort

7. Dextrose 5% – 1000 mL IV x2 doses

8. Sodium Cholride 0.45% 70 mL/hr for 14.3 hours

Student Name: XYZ 5

Patient’s Initials: J.M. Date: 11/09/2010

Primary Diagnosis: Exacerbation of COPD, Dehydration Patient’s Age: 97 Room Number: 460-A

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Physiological: Adequate oxygenation to Current electrolyte balance
Alert and Oriented x3 A
Oxygenation CNS Negative brain trauma
BP 123/51 A
Irregularly irregular pulse
Pulse: irregularly irregular; unable to Improper SA node Inadequate expansion &
I Anxiety r/t improper SA Node
calculate functioning recoil of arteries
firing
Rhonchi +Crackles noted
in upper lobes bilaterally
Rhonchi and crackles noted in RUL, and diminished breath
Air trapped in alveoli
LUL; Diminished breath sounds noted I Impaired gas exchange sounds bilaterally in lower
during exhalation
in RLL, and LLL lobes R/T impaired gas
exchange and current
exacerbation of COPD.
Resp rate: 20
Slightly labored breathing
Quickened rhythm; Alveoli inflamed causing
I Impaired ventilation Environmental allergens w/ nonproductive cough
Slightly labored breathing with non- air trapping
R/T impaired ventilation
productive cough
Skin: pink, warm and dry Adequate peripheral Adequate blood circulation Comfortable room
A
Nail bed refill: < 3 secs perfusion Current adequate hydration temperature
Heart sounds: A Proper timing and closing Autonomic nervous system
Aortic & Pulmonic valves: S2 > S1 of heart valves functioning
Erb’s Point: S1=S2
Student Name: XYZ
Mode & Subdivision Behaviors
Negative murmurs, clicks, rubs
Lab values:
RBC: 2.69 (norm 4.00 - 5.33)
Hgb: 8.6 (norm 12.0 - 16.0)
Hct: 25.8 (norm 36.0-46.0 % )
RDW: increased at 15.3%
Mode & Subdivision Behaviors
Physiological: Height: 5 ft 6 in
Nutrition Weight: 130 lbs
Appetite: desires food
Breakfast: 80%
Lunch: 60%
Oral Cavity:
Lips smooth, no lesions
Mucous membranes smooth, pink,
moist
Chews and swallows without effort
A/I
Focal
Red blood cell variations
I
A/I
Focal
Caloric intake equal caloric
A
expenditure
A Responds to hunger
Adequate hydration
A Adequate knowledge of
oral care
A Adequate tongue mobility
Adequate amount of teeth
Upper esophageal
sphincter intact &
functioning
Mandible intact
6
Stimuli Nursing Diagnosis
Contextual Residual
Abnormally low RBC,
Hgb, Hct and increased
Possible side-effect from RDW r/t red blood cell
Hemolytic Anemia
medication(s) variations as seen in
hemolytic anemia.
Stimuli Nursing Diagnosis
Contextual Residual
Functioning hypothalamus Diet
mechanism Genetics
Functioning hypothalamus
Likes hospital food
mechanism
Functioning salivary
glands (Parotid glands,
Doesn’t use drugs
submandibular, sublingual,
and buccal)
Cranial nerves V, IX, X, No history of esophageal
XII intact and functioning disorders
Student Name: XYZ 7

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Allergen does not trigger
Normal immune system Not exposed to all types of
Denies allergic reaction to food A body to respond to
functioning food
invasion

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Abdomen: soft, non-distended, non- Diet intake
Functioning
tender Intact autonomic nervous Adequate hydration
A gastrointestinal reflex
Bowel sounds present in all four system Negative history of
systems
Physiological: quadrants pathology
Elimination Defecation reflex
Bowel elimination once a day Rectal sphincter
functioning Adequate fluid intake
Negative change in bowel movement A functioning and within full
Sensory nerve fibers in Adequate peristalsis
or frequency control of patient
rectum intact

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Able to perform activity of daily living Absence of pain upon
without assistance Intact musculoskeletal movement Loves to do everything
A
ROM coordinated system Bone strength and muscle herself
Muscle strength is WNL strength adequate
Physical stability: Adequate bone strength
Physiological:
Balance and coordination intact Absence of pain
Activity and Rest A Cranial nerve VIII intact No pain
Demonstrates shortness of breath upon Proper body alignment
exertion Electrolyte imbalance
Interrupted sleep process
Interrupted sleep process (3-4 hours of Pain during coughing Increased pressure on Concerned about what the
I R/T pain during coughing
sleep while condition persists) episodes thoracic cavity future holds
episodes
Student Name: XYZ 8

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Knowledgeable about
Skin warm, dry and appropriate for Adequate peripheral Capillary perfusion
A proper skin care and
race perfusion functioning adequately
hygiene
Able to perceive pain and changes in Intact neurologic
A Intact receptors on skin No head trauma
temperature functioning
Adequate circulation
Skin turgor resilient A Adequate hydration Fluid volume balance Diet
systemically
Physiological: Effective dissipation of
Protection Evaporation from skin aids
Body temp: 98.9°F A heat produced by Heater in room functioning
in heat loss
metabolism
I.V. #22 heplock on left
Integrity: I.V. #22 heplock on left No signs of infiltration thoracic area below
Functioning immune Proper skin care
thoracic area below clavicle A/I No sign of formation of clavicle C,D,I R/T negative
system response Proper insertion of needle
Clean, dry, and intact hematoma signs of infiltration or
hematoma
Adequate production by Functioning lymphatic
WBC: 10.5 (norm 4.5 – 11.0) A Infection subsiding
bone marrow system

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Physiological: Vision: Patient states able to see “fine”
The Senses and denies need for corrective lenses
No problems with hearing
Focal
Natural curvature of eye
A promotes optimal light
utilization
A Intact internal and external
ear mechanism
Contextual Residual
No history of trauma to the
Cranial nerve II intact
eyes
Cranial Nerve VIII intact Negative history of head
and functioning trauma or significant ear
Student Name: XYZ
Mode & Subdivision Behaviors
Able to perceive touch, temperature
changes, and pain stimuli
Identifies smell in environment easily
and distinguishes between taste as
evidenced by desire for “good-tasting”
foods.
Mode & Subdivision Behaviors
Mucous Membranes: pink, moist
Skin tugor resilient
Physiological:
Fluid & Electrolytes
Alert and Oriented x3
Lab values:
Na 142 (norm 137 – 145)
K 4.1 (norm 3.5 – 5.0)
Cl 105 (norm 98 – 107)
Ca 8.5 (8.4 – 10.2)
A/I
Focal
CNS functioning properly
Able to perceive stimulus
A functioning has not been
coming from sensory
neurons
A/I
Focal
A Adequate hydration
submandibular, sublingual,
A Adequate hydration
Adequate oxygenation to
A Alert to presence of
CNS
Essential ions filtrated and
A conserved at nephrons of
kidney
9
Stimuli Nursing Diagnosis
Contextual Residual
infection
Cranial Nerves I, V, IX
intact and functioning
Patient’s cerebral
compromised
Stimuli Nursing Diagnosis
Contextual Residual
Functioning salivary
glands (Parotid glands,
No history of drug use
and buccal
Adequate circulation Uses daily moisturizing
Skin intact cream
Awake during time of day
Functioning medulla
oblongata
individuals in room
Negative history of renal
Adequate renal function
pathology
Student Name: XYZ
Mode & Subdivision Behaviors
Physiological:
Neurological Function Cranial Nerve I:
Able to smell and identify smells
Cranial Nerve II:
Denies problems with vision or need of
corrective lenses.
Cranial Nerve III:
Pupils and extraocular eye movement
equal
Consensual constriction and light
accommodation
Cranial Nerve IV:
Even, smooth, symmetrical movements
of both eyes
Cranial Nerve VI:
Able to laterally rotate the eyes
Cranial Nerve V:
Able to perceive touch, pain, and
thermal changes in the face
Able to chew food easily
Cranial Nerve VII:
Even, symmetrical movements of face
muscles
Able to perform wide variety of facial
expression without needed effort
Ability to different flavor profiles
(sweet, salty, sour, bitter)
10
A/I Stimuli Nursing Diagnosis
Focal Contextual Residual
Clean and clear nasal
No history of injury to nose
cavity
A Intact cranial nerve No history of serious nasal
Nasal secretion production
infections
within normal limits
Doesn’t expose eye to
A Intact cranial nerve Corneal lenses intact
harmful radiation
Muscles responsible for
A Intact cranial nerve No eye injury
ocular movement intact
Intact sensory-motor
receptors Negative history of injury to
A Intact cranial nerve
Adequate mandible face
strength
A Intact cranial nerve Intact facial muscles History of stroke has not
Intact taste buds affected significant areas of
brain
Student Name: XYZ 11

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Cranial Nerve VIII:
Patient does not display hearing
problems or balance and coordination
Cranial Nerve IX:
Patient is able to swallow fine
Patient gags when gag reflex is elicited
Cranial Nerve X:
Patient demonstrates ability to
swallow, cough effectively, and speech
does not cause problems or fatigue
Cranial Nerve XI:
Even, symmetrical movement of the
head
Negative signs of limited ROM or
difficulty when asked to perform ROM
of neck test
Cranial Nerve XII:
Full control of movement of tongue
No difficulty of speaking
Tongue does not deviate in one
direction when protruded
Focal
A Intact cranial nerve
A Intact cranial nerve
A Intact cranial nerve
A Intact cranial nerve
Contextual Residual
Intact cochlea & vestibule
Intact internal and external
Cleans her ears properly
ear
daily
Negative sign of cerumen
impaction
Intact stylopharyngeus
No history of esophageal
muscle
disease
Intact pharynx & larynx
Intact trapezius & No sign of paralysis to
sternocleidomastoid upper extremities of the
muscle body
History of stroke has not
Tongue movement within
affected movement of
full control
tongue

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Physiological: Growth & development WNL for age A Proper growth hormone Functioning pituitary gland Genetics
Endocrine regulation Adequate calcium intake Diet
Negative history of
Student Name: XYZ 12

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
osteoporosis
Functioning ovary gland
Secondary sex characteristics WNL A Proper estrogen regulation Genetics
Functioning pituitary gland
Diet intake
Abdomen: soft, non-distended, non- Functioning
Intact autonomic nervous Adequate hydration
tender A gastrointestinal reflex
system Negative history of
Bowel sounds present in all quadrants systems
pathology
Sympathetic nervous
Increased systemic BP 148/84 R/T increased
BP 148/84 I system response causing History of smoking
vascular resistance systemic resistance
vasoconstriction of arteries
The behaviors assess above revealed the patient suffered mostly from the oxygenation mode. The main concern was the inflammation of lower airways and systemic infection stemming from the
cancer in the lung.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Body Sensation:
Effective compensation by body Central nervous system intact
“Even with the radiation and chemo Denying what she
A during radiation and chemo Functioning feedback loop allow
therapy, I never felt that I was sick. No actually feels
therapy session body to maintain homeostasis
Self Concept: one even knew I had cancer.”
Physical Self Body Image:
Adequate physical development
Patient states that she’s “I make sure to Feels acceptance from close Husband loves
A Erikson developmental stage
always look presentable when I’m family and friends her for who she is
achieved
going out. I like to look good always.”
Student Name: XYZ 13

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Self-Consistency:
Not overwhelmed
Patient states, “I try not to let my Able to adapt to long term
A High self-esteem by current health
condition get the better of me. I take implication of cancer
problem
each day one at a time.”
Self-Ideal: Relies on
Self Concept:
“I really want to go back home, but I Activity intolerance disability funds Hopelessness R/T
Personal Self I Ineffective ventilation process
know I won’t be able to do the same Shortness of breath Doesn’t want to activity intolerance
things as before.” get better
Moral-Ethical-Spiritual Self:
Personal need of a higher being
Patient is Protestant and believes in A Strong belief in spiritual being Life experiences
helping patient cope
God but does not attend church.

The patient exhibited more problems than strengths in the self-concept mode. The patient illness affected his body sensation as well as his self-ideal. His coping strategies are ineffective due to
his fear of undesired situations.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Life experience
57 year old, female
Role Function: Achievement of role expectations contributed to
Mature adult A Desire to meet social standards
Primary Role of developmental stage normal
Generativity v. stagnation
maturation
Student Name: XYZ 14

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Role Function: Consumer: Children
Secondary Roles Mother Reward: Affection & close
Instrumental: Patient interacts with relationship
daughter and granddaughter that visit Access to facilities: phone,
Desires to maintain strong Raised children
her everyday. A privacy provided by staff and
relationship well
Expressive: Patient expressed roommate
gratitude for wonderful family support Cooperation & Collaboration:
system. Children visit patient everyday
in hospital
Wife Consumer: Husband
Instrumental: Patient remains in Reward: Maintain friendship and
Still cares about
contact with husband even though contact
husband but does
divorced. Patient claims “we are on Desire to maintain strong Access to facilities: privacy
A not want to
good terms.” relationship provided by nursing staff
burden him
Expressive: Patient states she does not Cooperation and Collaboration:
anymore
want to contact her husband because Full visiting rights and hours in
“it’s just going to worry him.” case ex-husband comes to visit
Consumer: grandchildren and
Grandmother great-grandchildren
Instrumental: Patient hugs, kisses, Reward: affection & close
Wants grandchild
and plays with granddaughter that relationship
and great-
visits. Access to facilities: phone and
A Enjoys presence of children grandchildren to
Expressive: Patient states, “I love all 6 visitation rights
know their
grandchildren. They make me so Cooperation and Collaboration:
grandmother
happy. Especially James, my full visitation rights for
daughter’s 2 year old son.” grandchildren and great-
grandchildren
Unemployed I Unable to perform arduous task Consumer: Husband Content with Interrole conflict R/T
Instrumental: Unable to work because without suffering from shortness Reward: Will not be able to being put on activity intolerance
of physical limitations. of breath or thoracic pain afford certain things disability
Expressive: “I’m living on disability Access to Facilities: Still able to
because of my condition. It’s very drive to supermarket, shopping
Student Name: XYZ 15

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
malls, etc.
hard to work with you have difficulty
Collaboration & Cooperation:
breathing.”
Federal government

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Role Function: Sick role
Tertiary Roles Instrumental: Patient is complaint
with all medical orders and lifestyle
Accepts medical prognosis Adequately presented all
modifications. Just telling staff
A Knows things will never be the information by healthcare and
Expressive: “In know that I have to to please them
same medical team
change in order to keep up with my
condition.”

The patient displayed role mastery in her primary and tertiary roles but has failure in her secondary role because of her unemployment status which might affect her health maintenance.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Patient indicates that she does not have
No concern of having significant Lack of significant
Interdependence a significant other but her ex-husband Divorced for 16 years and Distrusts potential
other present in patient’s life other R/T no concern
Mode: Significant has proved supportive during her I doesn’t want to find someone husbands because
Shows concern for disturbing her about have significant
Other ordeal. However she does not want to else of life experiences
ex-husband’s life other present
bother him with her problems.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Interdependence Patient has four children that range in A Wants to still be involved with Very instrumental in the Does not want to
Mode: Support age from 43 to 37. They have their family processes development of her children feel lonely
System own family to take care of but still Wants to ensure that the children Does not want to
make time for their parents, according do not get burdened by her feel distant from
Student Name: XYZ 16

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
to her. Patient stated that she is a
condition family
proud grandmother of 6 grandchildren.

Nursing Diagnosis:

1. Impaired gas exchange R/T inflammation of airways and alveoli

2. Acute pain R/T to increased respiratory rate secondary to alveolar inflammation of the lungs.

3. Anxiety R/T unpredictable or unstable course of illness

4. Ineffective health maintenance R/T inability to identify, manage, and/or seek help to maintain health

5. At risk for fluid volume deficit R/T decreased fluid intake

6. Imbalanced nutrition: less than body requirements R/T intake of nutrients insufficient to meet metabolic needs

7. Hopelessness R/T activity intolerance

8. Impaired swallowing R/T fatigue secondary to increased energy expenditure

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Impaired gas exchange R/T inflammation of
airways and alveoli
1. Assess patient’s respiration: quality, rate,
rhythm, depth, dyspnea on exertion, use of
accessory muscles, position assumed for easy
breathing
2. Monitor vital signs q4h
3. Monitor effects of positioning on oxygenation
levels (with the use of pulse oximetry)
1. Both rapid, shallow breathing patterns and Patient demonstrates
hypoventilation affect gas exchange. Use of decreased respiratory rate and
accessory muscles to breathe indicates an abnormal calmer appearance
increase in the work of breathing. Abnormality
indicates respiratory compromise. (Gulanick, M. & Patient maintains alert mental
Myers, J., 2007, p.482) status and does not show
2. With initial hypoxia and hypercapnia, blood evidence of respiratory
Student Name: XYZ 17

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

4. Maintain oxygen administration as ordered to
ensure oxygen saturation 90% or greater (95%
or greater is ideal). Avoid high concentrations
of oxygen in patients with COPD
5. Encourage use of incentive spirometer
6. Administer medication as prescribed carefully
and in a timely manner
7. Use optimal positioning and encourage
ambulation
pressure, heart rate, and respiratory rate all rise. As distress
the condition worsens BP and HR will drop and
arrhythmias may occur. Respiratory failure may
ensue when the patient is unable to maintain the
rapid respiratory rate needed to maintain
oxygenation. (Gulanick, M. & Myers, J., 2007,
p.366)
3. The semi-Fowler’s or high Fowler’s position allows
maximum chest expansion in clients who are
confined to bed, particularly those with dyspnea.
The nurse also encourages clients to turn from side
to side frequently, so that alternate sides of the
chest are permitted maximum expansion. (Berman
et al., 2008, p.1368)
4. Supplemental oxygen therapy maintain oxygen
saturation of 90% or greater to provide adequate
oxygenation. Careful administration of low liter
flow oxygen is indicated because hypoxia
stimulates the drive to breath in the patient who
chronically retains carbon dioxide. (Gulanic, M. &
Myers, J., 2007, p. 482).
5. Incentive spirometers measure the flow of air
inhaled through the mouthpiece and are used to
improve pulmonary ventilation, loosen respiratory
secretions, facilitate respiratory gaseous exchange,
and expand collapsed alveoli. (Berman et al., 2008,
1370).
6. Ongoing administration of antimicrobial agents
needs to be timely to maintain blood levels needed
to fight the organism adequately and prevent
relapse or the development of a resistant strain of
the organism. (Gulanick, M. & Myers, J., 2007,
p.367) Expectorants are used for productive
coughs and cough suppressants for hacking
nonproductive coughs. Bronchodilators and inhaled
steroids are used to open airway and decrease
Student Name: XYZ
Nursing Diagnosis
Scientific Knowledge Base (referenced):
Pneumonia is caused by a bacterial or viral
infection that results in an inflammatory
process in the lungs. It is an infectious
process that is spread by droplets or by
contact. It is one of the most common causes
of death in older adults. Predisposing factors
to the development of pneumonia include
upper respiration infection, excessive alcohol
ingestion, central nervous system depression,
cardiac failure, any debilitating illness, and
chronic COPD. At risk are patients who are
immunosuppressed, have a history of smoking
or who are malnourished or dehydrated.
(Gulanick, M. & Myers, J., 2007, p. 477).
Nursing Diagnosis
Acute pain R/T increased respiratory rate
secondary to alveoli inflammation of the lungs
Nursing Interventions
Patient/Patient/Family goal/expected outcome:
Short term goal:
Patient will exhibit signs and symptoms of
improved ventilation and oxygenation by
respiratory rate of 12 to 16 breaths/min and relaxed
comfortable appearance
Long term goal:
Patient maintains optimal gas exchange evidenced
by alert mental status and negative signs of
respiratory distress
Nursing Interventions
1. Assess pain characteristics: quality, severity,
location, onset, duration, and relieving factors
2. Observe or monitor signs and symptoms
associated with pain, such as BP, heart rate,
temperature, color and moisture of skin,
restlessness, and ability to focus.
3. Anticipate need for pain relief and respond
immediately to complaint of pain
18
Rationale for interventions (Referenced) Evaluation
inflammation. (Gulanick, M. & Myers, J., 2007,
p.481).
7. The sitting position and splinting the abdomen
promote more effective coughing by increasing
abdominal pressure and upward diaphragmatic
movement. Ambulation mobilizes secretions and
reduces atelectasis. (Gulanick, M. & Myers, J.,
2007, p.481)
Modification
If patient’s respiratory rate
increases or evidence of
respiratory distress occurs,
prepare to administer
emergency bronchodilator to
open up airways and
corticosteroids to prevent
further decompensation. If
patient continues to
decompensate prepare for
possible intubation and
mechanical ventilation.
Rationale for interventions (Referenced) Evaluation
1. Assessment of the pain experience is the first step Patient indicated pain level
in planning pain management strategies. Other decreased from 5 to 1
methods such as a visual analog scale or following 2 hours of nursing
descriptive scales can be used to indentify extent of intervention
pain. (Gulanick, M. & Myers, J., 2007, p.145)
2. Some people deny the experience of pain when it is Patient’s respiratory rate also
present. Attention to associated signs may help the decreased further helping in
nurse in evaluating pain. (Gulanick, M. & Myers, decreasing pain level.
Student Name: XYZ
Nursing Diagnosis
Scientific Knowledge Base (referenced):
Pain is a highly subjective state in which a
variety of unpleasant sensation and a wide
range of distressing factors may be
experienced by the sufferer. Pain may be a
symptom of injury or illness. Pain can be very
difficult to explain because it is unique to the
Nursing Interventions
4. Administer pain medication as ordered,
evaluating effectiveness and observing for
signs and symptoms of side effects
5. Instruct patient on relaxation exercises,
biofeedback, breathing exercises, imagery and
music therapy
6. Evaluate the patient’s response to pain and
medications or therapeutics aimed at
eliminating or relieving pain
Patient/Patient/Family goal/expected outcome:
Short term goal:
Patient will demonstrate decreased pain level
according to 1-10 pain scale
Long term goal:
Patient will correctly identify ways to manage pain
19
Rationale for interventions (Referenced) Evaluation
J., 2007, p. 145)
3. One can most effectively deal with pain by
preventing it. Early intervention may decrease
total amount of analgesic required. Prompt
responses to complaints foster the development of a
trusting relationship with the patient. (Gulanick, M.
& Myers, J., 2007, p.147)
4. NSAIDs work in peripheral tissues. Some block
synthesis of prostaglandins, which stimulate
nociceptors. They are effective in managing mild to
moderate pain. Opiods are indicated for severe pain
and local anesthetics block pain transmission in
specific areas of nerve distribution. (Gulanick, M.
& Myers, J., 2007, p.147)
5. Techniques are used to bring about a state of
physical and mental awareness and tranquility. The
goal of these techniques is to reduce tension,
subsequently reducing pain. (Gulanick, M. &
Myers, J., 2007, p.148)
6. It is important to help patients express as factually
as possible the effect of pain relief measures.
Discrepancies between behavior or appearance and
what the patient says about pain relief may be more
reflection of other methods that the patient is using
to cope with than pain relief itself. (Gulanick, M. &
Myers, J., 2007, p.34)
Modification:
If blood pressure continues to decrease watch for signs
of oxygen deprivation and prepare for airway
intubation and oxygen therapy.
Prepare for defibrillation if patient demonstrates
pronounced, life-threatening dysrhytmias.
Student Name: XYZ
Nursing Diagnosis
individual. Pain should always be addressed
by the primary care provider. (Gulanick, M. &
Myers, J., 2007, p.144).
Nursing Diagnosis
Anxiety R/T unpredictable or unstable course
of illness
Scientific Knowledge Base (referenced):
Nursing Interventions
through positioning and meditation
Nursing Interventions
1. Acknowledge awareness of the patient’s
anxiety
2. Reassure the patient that she can have someone
with her at all times.
3. Maintain a calm manner while interacting with
the patient
4. Establish a working relationship with the
patient through continuity of care
5. Reduce sensory stimuli by maintaining a quiet
environment
6. Assist the patient in developing anxiety-
reducing skills (ie. Relaxation, deep breathing,
positive visualization)
7. Use simple and easy statements in explaining to
patient about condition or procedures
Patient/Patient/Family goal/expected outcome:
20
Rationale for interventions (Referenced) Evaluation
Rationale for interventions (Referenced) Evaluation
1. Because anxiety cannot always be identified, the Patient became calmer when
patient may feel as though the feelings experienced the doctors assured her a
are not real. Assure the patient those feelings are concrete plan of care that
real and promote acceptance of those feelings. indicated possible discharge
(Gulanick, M. & Myers, J., 2007, p.16) from the hospital the next day.
2. The presence of a trusted person may be helpful When asked whether visitors
during an anxiety attack. . (Gulanick, M. & Myers, affected her level of anxiety
J., 2007, p.16) patient denied.
3. The health care provider can transfer his or her own
anxiety to the patient therefore it is important to Patient’s anxiety clearly
present a calm and non-threatening atmosphere. dropped as student nurse
(Gulanick, M. & Myers, J., 2007, p.16) conversed and joked with the
4. An ongoing relationship with the patient allows patient.
open communication regarding patient’s anxious
feelings. (Gulanick, M. & Myers, J., 2007, p.16)
5. Anxiety may escalate with excessive conversation,
noise and equipment around the patient. This is
true especially in hospital settings. (Gulanick, M. &
Myers, J., 2007, p.17)
6. Using anxiety-reduction strategies enhances the
patient’s sense of personal mastery and self-
confidence. (Gulanick, M. & Myers, J., 2007, p.17)
7. When experiencing moderate to severe anxiety,
patients may be unable to comprehend anything
more than simple, clear, and brief instructions.
(Gulanick, M. & Myers, J., 2007, p.17)
Modifications:
Student Name: XYZ 21

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Anxiety is a vague, uneasy feeling of
discomfort or dread accompanied by an
autonomic response. It is a feeling of
apprehension caused by anticipation of
danger. It is a signal that warns individuals of
impending danger and enables the individual
to respond to the threat. . (Gulanick, M. &
Myers, J., 2007, p.15)
Short term goal: Patient needs continued positive reinforcement
Patient will demonstrate calmer facial expression regarding her plan of care. She needs to be assured that
and demeanor. the interdisciplinary team is doing their best to alleviate
her condition.
Long term goal:
Patient will be able to verbalize ways to minimize
anxiety through the use of effective coping
mechanism

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Ineffective health maintenance R/T inability to 1. Assess for physical defining characteristics
identify, manage, and/or seek help to maintain 2. Assess the patient’s knowledge of health
health maintenance behaviors
3. Determine the patient’s specific questions
related to health maintenance
4. Provide the patient with rationale for
importance of behaviors such as following
proper nutrition
5. Involve family and friends in health planning
conferences
1. Changing ability or interest in performing the Patient feels that her
normal activities of daily living may be an indicator respiratory problems will
that commitment to health and well-being is keep coming back and seems
waning. (Gulanick, M. & Myers, J., 2007, p.96) to be affected by the fact that
2. Patients may know that certain unhealthy behaviors she will not be able to return
can result in poor health outcomes but continue the to her state of wellness prior
behavior despite this knowledge. The health care to her diagnosis of non-small
provider needs to ensure that the patient has all of cell lung cancer.
the information needed to make good lifestyle
choices. (Gulanick, M. & Myers, J., 2007, p.162) Patient is able to verbalize
3. Patients may have health education needs; meeting ways to maintain positive
these needs may be helpful in mobilizing the health maintenance behaviors
patient. (Gulanick, M. & Myers, J., 2007, p.162) but finds it difficult at times
4. The new MyPyramid approved by the Food and to abide by it.
Drug Administration provides guidance on
recommended food groups across a variety of
populations. Cardiovascular disease, cancer, type 2
diabetes, and osteoporosis are but a few of the
many medical diseases related to nutrition.
(Gulanick, M. & Myers, J., 2007, p.163)
5. Family members need to understand that care is
planned to focus on what is most important to the
patient. This enables the patient to maintain a sense
of autonomy. (Gulanick, M. & Myers, J., 2007,
Student Name: XYZ 22

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Scientific Knowledge Base (referenced):
Altered health maintenance reflects a change
in an individual’s ability to perform the
functions necessary to maintain health or
wellness. The nurse’s role is to identify factors
that contribute to an individual’s inability to
maintain healthy behavior and implement
measures that will result in improved health
maintenance activities. The task before the
nurse is to identify measure that will be
successful in empower patients to maintain
their own health within the limits of their
ability. (Gulanick, M. & Myers, J., 2007,
p.161)
p.163)
Patient/Patient/Family goal/expected outcome: Modifications:
Short term goal: Interdisciplinary team will continue to reinforce
Patient will be taught positive health maintenance materials presented to maintain positive heath
behaviors such as keeping appointments, avoiding maintenance to patient. Patient must be reminded as to
drugs and alcohol, making diet and exercise the benefits of maintaining a healthy lifestyle as well as
changes, improving home environment, and the risk of failing to do so.
following treatment regiment.
Long term goal:
Patient will identifies available resources and uses
available resources for continued positive health
maintenance prior and after discharge.

Discharge Planning

A. Has the illness experience brought changes to the patient’s role, self-concept, and interdependence? Is this a temporary or permanent health status change? Will the change affect family

dynamics/function?

As the patient clearly expressed, she hasn’t let her current condition affect her life much. As a 57 year old independent individual, she still carries on her day to day life to the best of

her abilities. Her role now has changed from working a full-time job to relying on disability funding from the government. However she does not feel that her view of herself has

changed. As she stated, “I really won’t let this cancer get the better of me.” The patient doesn’t like to be dependent on anyone because of her strong personality, but she has

indicated that her daughter knows that she will need more assistance now that her condition has deteriorated. As a stage IV cancer patient, she knows that her disease will cause

further problems in the future, and she has accepted that reality. Although the patient tries to cope with the prospect of dealing with her condition and attempts to hide her anxiety, it is

evident in her conversation with staff and visiting family members. As for her family, the daughter claims they haven’t been quite affected because as she said, “Our mom is really
Student Name: XYZ 23

strong. She’s going to get through this with or without our help. It’s up to her how much we should get involved.” The patient has said that she will try to do everything herself to the

best of her ability, and will only ask for assistance if absolutely necessary.

B. Identify what criteria serve as the basis for determining readiness for discharge of this patient from the acute care setting.

After speaking with the case manager, the discharge plan for the patient is to go home with follow-up respiratory rehabilitation on outpatient basis. The doctor spoke with the patient

as to the importance of avoiding activities that might cause another infection. The nurse must assess vital signs to ensure stability. Lung sounds must also be clear before discharging

the patient to ensure that her respiration is no longer compromised. In addition to this the patient must have adequate discharge teaching to prevent further incidence of hospitalization

due to another infection. In collaboration with the dietician, the patient must be taught how to manage her diet to ensure her metabolic needs are met and essential nutrients are

absorbed by the body to help strengthen her immune system. Furthermore the interdisciplinary team must be wary of the required follow-up visits by the patient after being discharge

to home, especially since her therapeutic regiment will be ongoing.

C. What measures did you take to promote an effective discharge transition by the patient/family in this situation?

Speaking with the case manager, primary physician, respiratory therapist, and dietician I was able to determine an effective transition means for the patient. Once the patient is stable

and ready to go home, I must ensure that she has the necessary support system to assist her with her daily needs and to make sure those medications that she will continue to take are

fully explained to her. Because the patient will be discharge to home, and she is a 57 year old individual that is more than capable of taking care of her ADLs, my main concern lay

with her knowing how to maintain a high degree of wellness after discharge. Because she will continue to receive therapy for her cancer and further respiratory rehabilitation

afterwards, I must reinforce with the patient the importance of keeping to her scheduled appointments on the outpatient basis. Nutrition and avoiding infection was top priority in

discharge teaching for the patient. Her cancer therapy regiment has weakened and will continue to weaken her immune system so avoiding instances where she might acquire another

infection from the community was top priority in discharge teaching. Furthermore, her nutritional status discussed ways for her to consume high calorie and nutritionally dense foods

to meet her metabolic demands as well as provide her with the necessary vitamins and mineral to strengthen her body during her cancer therapy. The patient had to understand all

these before an effective discharge from the hospital could take place.
Student Name: XYZ 24

D. What actions/interventions contributed to the safe discharge of the patient?

The only way for the patient to be safely discharged from the hospital is for the whole healthcare team to collaborate in the care of the patient. These included anticipatory teaching by

the nurse, consulting with the case manager for the best place to discharge patient, treatment explanation by the respiratory therapist, and nutritional assessment by the dietician. As

the student nurse, I had to present this to the patient in such a way that facilitated understanding. Anticipatory teaching was foremost and reinforcement of materials taught became top

priority. As the student nurse in charge of the patient, positive reinforcement became top priority and the patient had to understand her treatment regiment must be followed in order to

ensure a high degree of wellness even during her cancer treatment regiment. Once the patient adequately identified positive health maintenance behaviors the treatment team can rest

assured that the patient can be safely discharged.

References:

Andrews, H. & Roy, C. (1999). The Roy Adaptation Model. Stamford: Appleton & Lange.

Berman, A., Erb, G., Kozier, B., & Snyder, S. (2008). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. Upper Saddle River: Pearson Prentice Hall.

Carpenito-Moyet, L. (2008). Handbook of Nursing Diagnosis. Philadelphia: Lippincott Williams & Wilkins

Gulanick, M., & Myers, J., (2007). Nursing Care Plans: Nursing Diagnosis and Intervention. St. Louis: Mosby Elsevier.

Monahan, F., Sands, J., Neighbors, M., Marek, J., & Green, C. (2007). Phipp’s Medical-Surgical Nursing: Health and Illness Perspectives. (8th ed.) St. Louis: Mosby Elsevier.

Lewis, S., Dirksen, S., Heitkemper, M., O’Brien, P., & Bucher, L. (2007). Medical Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis: Mosby Elsevier.

Holloway, N. (2004). Medical-Surgical Care Planning. Springhouse: Lippincott Williams & Wilkins.

http://www.pulmonologychannel.com/copd/overview-of-chronic-obstructive-pulmonary-disease.shtml

http://www.lungusa.org/lung-disease/copd/about-copd/understanding-copd.html