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Nursing Careplan

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Nursing Care Plan
Mohave Community College
Nur 122. Nursing 2
November 8, 2011

MOHAVE COMMUNITY COLLEGE
NURSING DEPARTMENT
NURSING CARE PLAN
NUR 122

ASSESSMENT
A. ADMISSION DATA
Date of admission 10/07/11 Client initials CW
Medical diagnosis COPD/Leukocytosis
Age 65 Sex Female Marital Status Divorced
Ethnicity Caucasian Religion Catholic
Vital signs upon admission:
B/P 107/61 P 98 R 20 T 97.6 Ht 5’4 Wt 99.9lbs
Allergies C.W. is allergic to ASA, it causes her to have an upset stomach.
B. HEALTH-ILLNESS TRANSITION
History of present illness C.W. is a 65 year old female with a history of COPD. She has been admitted to the hospital on several different occasions for a COPD exacerbation. C.W. was admitted through the ER on October 7, 2011 for an increased cough, shortness of breath, which got progressively worse with chest tightness. C.W.’s most recent hospitalization was on September 13, 2011 for a pneumothorax. She was also admitted sometime in August for a COPD exacerbation.
Significant client health history (include family history) C.W. is a 65 year old female who lives with her ex-husband. She has a history of leukocytosis, anemia, hyponatremia, COPD, valley fever, chronic pain syndrome, back pain, osteoporosis, small-bowel obstruction, peripheral neuropathy, constipation, and pneumothorax. C.W. also admits to being a current smoker. She smokes approximately 1½ packs per day. C.W. has a family history of hypertension, diabetes, and peripheral neuropathy. C.W. stated that she recently lost her sister who suffered from a massive heart attack.
Pathophysiology of primary diagnosis (definition, etiology, signs and symptoms. Underline behavior exhibited by this client. Cite reference.) Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. Airflow limitation usually is progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases and characterized inflammation throughout the airways, parenchyma, and pulmonary vasculature. COPD is a debilitating condition of the lungs that affects the individuals ability to work and function independently. (Bare, Cheever, Hinkle, & Smeltzer, 2010, pp. 231-234) The etiology of COPD is smoking, air pollution, airway destruction, occupational exposure to noxious dust and gas, and an airway infection. (Bare, Cheever, Hinkle, & Smeltzer, 2010, pp. 231-234) Some signs and symptoms that may be present in a patient with COPD are chronic cough, sputum production, dyspnea on exertion, frequent infections, abnormal ventilation, hypoxemia, and hypoventilation. (Bare, Cheever, Hinkle, & Smeltzer, 2010, pp. 231-234)
4. Holistic assessment
a. Physiological integrity
|System |Subjective Data |Objective Data |
|Cardiovascular |Patient stated upon admission she had chest |BP: 110/66 |
| |tightness, which was related more to her COPD |HR: 92 (Apical Pulse) |
| |exacerbation. Patient stated she has a history of|Capillary Refill: Brisk (WNL) |
| |anemia. |Radial Pulses: Strong (equal) |
| | |Pedal Pulses: Strong (equal) |
| | |Heart sounds: Normal |
| | |Edema: localized Bil LE |
|Respiratory |Patient states she has no complaints of |Rate/Effort lungs: Regular |
| |respiratory issues at this time, although she |Right and left clear breath sounds |
| |does have COPD. Upon admission she had some chest|Productive cough present (Clear phlegm) |
| |tightness. Patient is a smoker, she has been for |Respiration Rate: 18 |
| |48 years and smokes 1½ packs a day. Patient has a|Pulse OX: 91% on 2.5 L O2 NC |
| |history of valley fever. | |
|Gastro-intestinal |Patient verbalized her last bowel movement was |Abdomen soft during palpation. |
| |10-10-11 |Bowel sounds present during auscultation |
| |Patient stated she can’t make it to bathroom |Patient wearing depends due to incontinence |
| |(incontinent) | |
| | | |
|Genito-urinary |Patient stated she has difficulty getting to the |Patient wearing depends d/t incontinence. |
| |bathroom in time. She stated she has no other |Urine appeared to be clear, yellow |
| |complaints voiding. |Sufficient amount |
| | | |
| | | |
|Neuro/Sensory |Patient stated she has a history of peripheral |Patient alert and oriented times three. |
| |neuropathy. |Person, Place, Time. |
| |Pt wears glasses |Pupils are round and reactive to light. |
| | |Patient wears glasses |
| | |Patient has no hearing impairment |
|Musculoskeletal |Patient has a history of falls within the last |Patient is bedridden |
| |week. She states that she is weak. She also |Generalized weakness |
| |states her joints ache and cause pain which is |Patient grasps equally on both sides |
| |not new. |Patient strength is equal on both sides |
| |Patient states she has a history of osteoprosis |Patient is cachectic looking, and very frail. |
|Skin |Patient stated the wounds on her coccyx hurts. |Dry skin |
| | |No apparent rash |
| | |Dressing covering coccyx. Under the dressing |
| | |appears to be a reddened opened wound. |
| | | |

b. Psychosocial integrity Client’s perception of effect of illness/surgery on self-concept C.W. is having a difficult time coping with being in the hospital. She states she is “miserable and just wishes she could go home”. She said she is in the hospital way too much. C.W. indicated her family has been a great support system for her. Her ex-husband and daughter come visit daily. She stated her daughter just had a baby a couple months ago, which makes her want to really go home.
Client’s affect C.W. is a relatively friendly individual. The patient uses proper manners, and is able to verbalize her needs and concerns without hesitation. C.W. is aware of her current condition and understands why she is in the hospital. She states that she wishes she never started smoking, because of all the difficulties it has caused her. She also stated she doesn’t think she’ll ever quit smoking, its just to hard.
Coping mechanisms C.W. stated that when at home she crochets a lot to get her mind off of things. She states she also sleeps when feeling down.
c. Cultural considerations
Role: marital status, children, parents, etc. C.W. is divorced with one child. She has been divorced for 10 years. C.W. stated her daughter resides here in Bullhead City. She has one grandchild that was just born a couple months ago. C.W. lives at home with her ex-husband. When she is at home her ex-husband helps her perform all her ADL’s because of her weakness. She stated her daughter comes to visit her four times a week. Patient states both her father and mother are deceased.
2. Client’s preferences unique to culture: hygiene, diet support Patient had no specific preferences to hygiene or diet support. She complained about being NPO status. Patient was placed on NPO status d/t EGD. After getting the EGD she was placed on a cardiac diet with a 1000cc fluid restriction. Other than not being able to eat for 8 hours C.W. had no complaints.
3. Compliance with health care plan C.W. is compliant and cooperative with the all aspects of patient care. She is open to learning and takes her routine medications.
d. Spiritual state C.W. stated that she wasn’t a very religious person and hasn’t gone to church in quite some time. However she stated she was raised as a catholic.
Client’s statements that reflect joy/purpose of living vs. hopelessness C.W. stated how much she enjoys being around her daughter and grandchild. She stated she can’t wait to get home so she can see her grandkid. C.W. stated she is depressed and hates being sick. She stated it is very difficult to do anything now days because of her COPD. She hopes to live long enough to see her grandchild go to school. Her daughter and her grandchild are what keep her going.
2. Client’s inner strength/weaknesses C.W. is very weak and is unable to do much of anything on her own. She relies a lot on her ex-husband when at home. It seems as if C.W. has a lack of motivation. She is very malnourished and frail. C.W. gets agitated at times and feels miserable. She states not being able to do much of anything makes her frustrated. She hopes to get home soon to be with her daughter and grandchild.
5.
|Diagnostic Tests |Results |Indicate possible reasons for abnormal |
|(including blood work, |(abnormals in red) |results |
|x-rays, scans, etc.) | | |
|1. Chest Xray-2 views |Severe COPD with biapical changes noted. |Smoking, COPD |
|2. Abdominal and Pelvic CT scan (10-8-11) |Severe right lower lobe infiltrate appears |Ascites |
|3. Abdominal Ultrasound (10/11/11) |slightly improved. |Ascites |
|4. EGD |Bibasilar infiltrates, collapsed |CBC: |
|5. Parcentesis with CT guidance |gallbladder, large volume abdominal and |WBC, leukocytosis |
|6. CBC |pelvic ascites, distended bladder. |RBC: anemia |
|7. Cardiac marker panel |There is a small perihepatic fluid present.|HGB: dropping could be a sign of bleeding |
|8. BMP |No liver mass, No evidence of |HCT: dropping could be a sign of bleeding |
|9. TSH |cholelithiasis. |PLTCT: An increase could be d/t acute |
| |Negative |infections and inflammatory disease |
| |No fluid drained |(Dunning, M.B., & Frances, F., 2011, pp. |
| |6. CBC: |213-220) |
| |WBC: 10/7: 15.8 |8. BMP: |
| |10/8: 14.3 |Electrolytes can be imbalanced d/t |
| |10/9: 17.0 |anorexia. |
| |10/10: 14.0 |NA: a decrease in sodium could be d/t hx of|
| |10/11: 16.7 |hyponatremia, and being NPO and anorexia. |
| |RBC: 10/7: 2.91 |(Dunning, M.B., & Frances, F., 2011, pp. |
| |10/8: 2.24 |258-264) |
| |10/9: 3.49 |9. TSH: |
| |10/10: 3.98 |A increased TSH test could mean |
| |10/11: 3.58 |hypothyroidism. |
| |HGB: 10/7: 10.0 |Dunning, M.B., & Frances, F., 2011, pp. |
| |10/8: 7.6 |552-555 |
| |10/9: 11.2 | |
| |10/10: 13.1 | |
| |10/11: 11.8 | |
| |HCT: 10/7: 28.4 | |
| |10/8: 22.5 | |
| |10/9: 35.7 | |
| |10/10: 40.3 | |
| |10/11: 33.4 | |
| |MCV: WNL | |
| |MCH: WNL | |
| |MCHC: WNL | |
| |RDW: 10/7: 18.4 | |
| |10/8: 18.5 | |
| |10/9: 18.1 | |
| |10/10: 18.3 | |
| |10/11: 17.5 | |
| |PLTCT: 10/7: 586 | |
| |10/8: 640 | |
| |10/9: 506 | |
| |10/10: 442 | |
| |10/11: 443 | |
| |MPV: WNL | |
| |Rbcmorph: 10/7: abn | |
| |10/8: abn | |
| |10/9: abn | |
| |10/10: abn | |
| |10/11: abn | |
| |ANISO: WNL | |
| |Neutroph: 10/7: 85 | |
| |10/8: 89 | |
| |10/9: 92 | |
| |10/10: 96 | |
| |10/11: 98 | |
| |Monocyte: WNL | |
| |Lymphocy: WNL | |
| |7. CKMB: 10/7: 2.5 | |
| |Trop I: 10/7:…...

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