Case Study 1 NCP

Assessment

Subjective:

Patient reports severe epigastric abdominal pain of sudden onset, radiating to the
back, continuous, and increasing in intensity.
Patient reports mild pain relief when leaning forward.
Patient reports dyspnea without chest pain.
History of heavy smoking.
No significant medical or surgical history.
Past medical history is unremarkable.

Objective:

Vital signs on arrival:

Heart rate: 130 beats per min
Temperature: 37.2°C
Blood pressure: 100/70 mmHg
Oxygen saturation: 92%
Tenderness in the epigastric area on examination.
Elevated white blood count (14×109/L) on laboratory testing.
Normal findings on electrocardiogram.
Right pleural cavity decompression and chest tube insertion performed with
subsequent symptom relief and lung expansion.
Discharge from the hospital after four days with no symptoms.

Nursing Diagnosis

 Acute Pain related to inflammation and distension of the pancreas and surgical
interventions (pleural decompression and chest tube insertion)

 Risk for Infection related to invasive procedures (chest tube insertion) and
compromised immune system function.

Planning

 Alleviate pain and discomfort.

 Monitor and stabilize vital signs.
 Promote respiratory function and lung expansion.
 Provide patient education on smoking cessation and lifestyle modifications.
 Ensure proper wound and chest tube care.
 Prepare the patient for discharge.
 Prevent recurrence of pancreatitis.
 Support the patient in smoking cessation efforts.
 Promote a healthy lifestyle to reduce the risk of future health issues.
 Ensure the patient's understanding of post-discharge instructions and follow-up
care.

Implementation

Independent

 Administer pain medication as ordered.

 Encourage the patient to assume a position of comfort (leaning forward).
 Encourage deep breathing and coughing exercises.
 Educate the patient on the importance of smoking cessation.
 Discuss the benefits of a healthy diet and avoiding alcohol.
 Educate the patient on signs of infection or complications to report.
 Review post-discharge instructions.
 Ensure the patient has necessary prescriptions and understands medication
regimens.
 Schedule follow-up appointments.
 Encourage adherence to a low-fat diet and lifestyle modifications.
 Discuss the importance of regular medical check-ups.
 Provide ongoing counseling and support.
 Offer dietary and exercise guidance.
 Emphasize the importance of maintaining a healthy weight.
 Confirm the patient's ability to manage medications and appointments.
 Address any concerns or questions the patient may have.

Dependent

 Continuously monitor heart rate, blood pressure, and oxygen saturation.

 Notify the healthcare provider of any significant changes.
 Monitor respiratory rate and effort.
 Assist the respiratory therapist with chest tube care.
 Administer oxygen therapy as prescribed.
 Refer the patient to a smoking cessation program if available.
 Monitor the chest tube for proper functioning and drainage.
 Perform dressing changes as ordered.
 Connect the patient with smoking cessation resources.
Rationale

 Pain relief is essential to enhance patient comfort and improve their ability to
cooperate with treatment and recovery.
 Leaning forward may help relieve pain by reducing pressure on the pancreas and
promoting comfort during acute pancreatitis.
 Chest tube care requires specialized knowledge and skills, and collaboration with
the respiratory therapist ensures proper management of the pleural effusion
and pneumothorax.
 Oxygen therapy is necessary to maintain adequate oxygenation in patients with
respiratory compromise due to pleural effusion and pneumothorax.
 Smoking cessation is crucial for reducing the risk of future health issues,
including pancreatitis recurrence.
 Patient education empowers the patient to recognize and report early signs of
infection or complications, allowing for timely intervention.
 Ensuring the patient understands and can follow post-discharge instructions is
essential for a successful transition to home care.
 Medication adherence is crucial for managing pancreatitis and preventing
complications.
 Follow-up appointments facilitate ongoing monitoring and evaluation of the
patient's condition, allowing for early intervention if needed.

 Frequent vital sign monitoring is necessary to detect any signs of deterioration

or complications, such as hemorrhage or sepsis.
 Promptly informing the healthcare provider allows for timely assessment and
intervention if vital signs become unstable or abnormal.
 Monitoring respiratory status is critical as the patient experienced a
pneumothorax.
 Changes in respiratory rate or effort could indicate respiratory distress.
 These exercises help prevent atelectasis, improve lung function, and prevent
complications such as pneumonia.
 Lifestyle modifications, such as dietary changes and alcohol avoidance, can help
prevent pancreatitis and improve overall health.
 Referring the patient to a specialized program can provide additional support
and resources for smoking cessation.
 Proper chest tube function is essential for effective drainage of pleural effusion
and pneumothorax.
 Dressing changes prevent infection and maintain the integrity of the chest tube
insertion site.
Evaluation

 Short-term goals should be evaluated continuously during the patient's hospital

stay.
 Long-term goals should be assessed during follow-up appointments.
 Successful pain relief, stable vital signs, and improved respiratory function
indicate progress in care.
 The patient's understanding and commitment to lifestyle changes and smoking
cessation should be evaluated during follow-up visits.

Case Study 2 NCP

Assessment

Subjective:
 Mr. Angelo, a 58-year-old chronic smoker with a 40-year history, newly
diagnosed with chronic obstructive pulmonary disease (COPD).
 History of hypertension treated with Amlodipine.
 Shortness of breath that has progressively worsened over the past 4 days,
associated with wheezing and cough with mucoid sputum.
 Chronic intermittent cough with mucoid sputum for the past 3 years.
 Persistent breathlessness for the past year, especially on exertion.
 No previous treatment sought for these symptoms.

Objective:
 Tachypneic with a respiratory rate of 28 breaths per minute.
 Increased anterior-posterior chest diameter, use of accessory muscles, and
reduced cricosternal distance.
 Generalized rhonchi and coarse early inspiratory crepitations on lung
auscultation.
 Hyperinflated chest on chest X-ray, tubular heart, and absence of vascular
markings.
 Sinus rhythm with low voltage on ECG.
 Vital signs: Pulse rate 72 bpm, BP 129/73 mmHg, Temp 37°C, SpO2 95% with 3
liters/min of nasal prong oxygen.
 Mildly elevated jugular venous pressure.
 Barrel-shaped chest with reduced chest expansion.
 Hyperresonance on lung percussion with loss of liver and cardiac dullness.
 Fine early inspiratory crepitations at lower lung zones.
 Mild bilateral pitting edema.
Nursing Diagnosis

 Ineffective Breathing Pattern related to chronic obstructive pulmonary disease

(COPD) and acute exacerbation.

 Impaired Gas Exchange related to ventilation-perfusion mismatch associated

with COPD.

 Ineffective Airway Clearance related to increased production of mucoid sputum

and airway inflammation.

 Knowledge Deficit related to COPD management, including inhaler use and

smoking cessation.

Planning
 Improve Mr. Angelo's breathing pattern.
 Enhance gas exchange and oxygenation.
 Facilitate effective airway clearance.
 Provide education on COPD management.
 Help Mr. Angelo manage his COPD effectively.
 Encourage smoking cessation.
 Prevent exacerbations and complications.
 Enhance Mr. Angelo's knowledge of COPD self-management.

Implementation

Independent
 Encourage and assist with relaxation techniques and breathing exercises.
 Monitor respiratory rate, effort, and lung sounds regularly.
 Elevate the head of the bed and encourage proper positioning to optimize lung
expansion.
 Encourage Mr. Angelo to perform effective coughing techniques.
 Ensure adequate hydration to loosen and thin secretions.
 Educate Mr. Angelo on the proper use of metered-dose inhalers (MDIs) for
Ipratropium Bromide and Salbutamol.
 Discuss the importance of smoking cessation and refer to smoking cessation
programs or resources.
 Teach Mr. Angelo about the signs and symptoms of COPD exacerbations and
when to seek medical attention.
 Develop a COPD action plan with Mr. Angelo, including medications, inhaler use,
and self-monitoring.
 Schedule regular follow-up appointments to monitor COPD progression and
medication effectiveness.
 Provide ongoing support and encouragement for smoking cessation.
 Educate Mr. Angelo on avoiding triggers, such as respiratory infections and
exposure to smoke or pollutants.
 Continuously assess Mr. Angelo's understanding and adherence to the COPD
management plan.
 Address any questions or concerns Mr. Angelo may have about his condition or
treatment.

Dependent
 Administer prescribed bronchodilators and monitor their effectiveness.
 Administer oxygen therapy as prescribed, and monitor SpO2 levels.
 Provide chest physiotherapy as ordered to help mobilize secretions.
 Refer Mr. Angelo to smoking cessation programs or resources.
 Ensure Mr. Angelo receives vaccinations, including influenza and pneumococcal
vaccines, as appropriate.

Rationale
 Relaxation techniques and breathing exercises can help reduce anxiety, decrease
respiratory muscle tension, and improve breathing patterns in patients with
COPD.
 Frequent monitoring allows for early detection of changes in respiratory status
and the effectiveness of interventions.
 Elevating the head of the bed and positioning the patient correctly can reduce
the work of breathing and enhance lung expansion, improving gas exchange.
 Coughing helps clear mucus and secretions from the airways, improving airway
patency.
 Proper hydration helps keep mucus thin and more manageable, aiding in
effective coughing and mucus clearance.
 Proper inhaler technique is essential for medication delivery and optimal
symptom control in COPD.
 Smoking cessation is critical to slow disease progression and reduce
exacerbation risk. Referral to programs or resources can provide additional
support.
 Early recognition of exacerbation symptoms empowers the patient to seek
prompt medical care, potentially preventing severe exacerbations.
 A well-defined action plan helps the patient take control of their condition and
manage symptoms effectively.
 Regular follow-up appointments allow for ongoing assessment of COPD
management and adjustments to the treatment plan as needed.
 Smoking cessation support is vital to help Mr. Angelo quit smoking, reducing the
progression of COPD and the risk of exacerbations.
 Awareness of triggers can help Mr. Angelo make lifestyle adjustments to reduce
the risk of exacerbations.
 Regular assessment ensures that Mr. Angelo is actively engaged in self-
management and understands his role in maintaining health.
 Open communication allows for clarification of doubts and reinforces patient
education, leading to better adherence to the treatment plan.

 Bronchodilators help relax airway smooth muscles and improve airflow.

Monitoring their effectiveness ensures appropriate medication management.
 Oxygen therapy improves oxygenation in patients with impaired gas exchange
due to COPD exacerbation. Monitoring SpO2 levels ensures the patient is
adequately oxygenated.
 Chest physiotherapy techniques, such as postural drainage and percussion,
assist in loosening and clearing mucus from the airways.
 Specialized programs and resources can provide additional guidance and
support tailored to the patient's smoking cessation needs.
 Vaccinations can reduce the risk of infections that can exacerbate COPD and
lead to complications.

Evaluation

 Mr. Angelo's respiratory status, including breathing rate, effort, and lung sounds,
should be regularly assessed. If there is a trend of improvement and
stabilization, it indicates the effectiveness of the care plan.

 Monitoring of Mr. Angelo's oxygenation through SpO2 measurements should

continue. A sustained improvement in SpO2 levels within the target range
suggests that the care plan is effective in enhancing oxygen levels.

 Symptom improvement, such as decreased dyspnea, reduced cough, and

improved mucus clearance, should be documented. Consistent progress in these
areas demonstrates the success of the interventions.

 Any deviations or lack of progress should trigger a reassessment of the care

plan. Adjustments, if needed, should be made promptly to better align with Mr.
Angelo's evolving needs and to achieve the established goals.