Advanced Nursing Practice:Nursing Care Plan Abstract. A nursing care plan is an integral component in the management of all patients seeking medical services. Such is the case given its advantage of enabling the nurses to individualize the care provided to patients per their needs. It involves three key elements that inform its existence. They include the assessment data, diagnosis or client problem, and nursing interventions.
In the assessment phase, the nurse acquires patient’s subjective and objective data that will facilitate his/her judgment about the patient’s clinical problem in the diagnosis step. With the identified client’s problems, the nurse can thus institute appropriate nursing strategies that will relieve these health problems.
Keywords: Nursing care plan, Assessment, Diagnosis, Intervention
Advanced Nursing Practice:Nursing Care Plan
All patients coming to seek health care services have an entitlement to the individual specific care plan. Such is the case given the individualistic nature of one’s health care needs. Thus, nurses have a lead role in ensuring that their patients receive this kind of care. Pertinent to this care is assessment, diagnosis, and appropriate nursing interventions. In essence, designing a comprehensive care plan for a sick person is the center of intrigue in this discussion. Central to this are the patient’s assessment, ICD-10 diagnoses and nursing interventions that are specific to the case scenario.
Care Plan Template
Patient Initials: C.FAge: 65Sex: Female
Subjective Data
Client Complaints: Cough (2/52), fever (2/7), loss of appetite
HPI (History of Present Illness)
The onset of the chief complaint (coughing) dates back two weeks ago. The patient also has had a fever for two days and has continuously experienced decreased appetite with no associated nausea and vomiting. The nature of the patient’s cough is dry and occurs mainly at night. Its relief is through taking a sitting position. Past treatment that has been effective in relieving these symptoms includes the use of inhaler and antibiotics. However, currently, the patient is not on any of the therapeutic strategies.
PMH (Past Medical History)
Firstly, the patient had asthma in her childhood and as per now has never been admitted before but has undergone a hysterectomy procedure. Past medication use, suggests that the patient has been using antibiotics and inhalers for the similar problem in the past. Moreover, on admission, she was not any medications, but she has utilized over-the-counter Tylenol for pain in the past. Lastly, she is allergic to all drugs that contain sulfa as an element.
ROS
She has activity-induced shortness of breath, but she is free from chest pressures. Moreover, she reports having fever with no signs of diaphoresis. Lastly, she has no noticeable palpitations as well as nausea and vomiting.
Significant Family History
Of interest is that she has two sisters who are both nursing chronic conditions namely; osteoporosis and breast cancer. Thus, the patient is a risk factor for cancer of any kind due to genetics.
Social/Personal History
Firstly, the patient is a widow who is economically independent as she has an entitlement to an annual pension worth $40,000 and has an education attainment of high school diploma. She has a primary care provider, whose schedule is very tight that leaves her with time-limited care. Furthermore, she has medical insurance, but it does not fully cover the cost of her prescribed medications.
That notwithstanding, she is a retired hairdresser with positive health beliefs that cherish maintenance of healthy lifestyle. She has good dietary practices and limited exercise programs given her shortness of breath.
Lastly, she is a renowned chronic smoker who has been taking one pack of cigarettes per day for 40 years. She reports no use of either alcohol or any other illegal street drug.
Description of Client’s Support System
She has a readily available support system that includes her daughters and church colleagues. Her daughters visit once every month, but she desires for more involvement of her daughters in her life.
Behavioral or Nonverbal Messages
Behaviorally, she has to put up with staying indoors for extended periods given the state of her condition. Besides, she acknowledges that staying indoors has contributed significantly to her depressed mood in the recent years.
Client Awareness of Abilities, Disease Process, Health Care Needs
She is fully aware of her predicaments as she reports to have a reduced self-efficacy for a timeframe of ten years. Moreover, she demonstrates an understanding of the aggravating factors. Such is the case given her assertion that depression has a role to play in worsening her condition by exacerbating the physical symptoms that she is experiencing.
Objective Data:
Vital Signs
Of significance to her condition, she has a regular, non–labored and normal respiratory rate of 20breaths per minute (16-24breaths/minute). Also, she has a normal blood pressure of 130/72mm/Hg (110/70-140/90mm/Hg). However, her BMI (130/ 1.72= 45 kg/m2) is on the higher side since it is above the normal range of 16.5 to 24.5kg/m2. Thus, she is an obese patient.
Physical Assessment Findings
On HEENT examination, she has a significant white material on her mucosa of the buccal cavity, possibly an oral thrush due to chronic use of inhalers that suppress the immune system.
Additionally, on examination of the respiratory system, she has diminished bilateral breath sounds. Also, she has a dull sound on percussion of the lower lobe of the lungs, which is suggestive of pleural effusion. Wheeze sounds are also present on auscultation. The patient also has an increased anterior-posterior diameter of the chest wall that is common in patients with Chronic Obstructive Pulmonary Disease (COPD).
Finally, of interest to her condition, the patient has a normal and regular heart rate, and rhythm. Evidently, this points to the efficient cardiovascular system that has no association with the patient’s condition.
Lab Tests and Results
Her complete blood count indicates leukoplakia since the White Blood Cells count is at 15,000 with a shift to the left.
Moreover, the chest x-ray suggests hyperinflation of both lungs with an increased anterior-posterior diameter, which is indicative of emphysema.
Lastly, the EKG indicates a normal sinus rhythm, which further proves the non-involvement of the cardiovascular system in the development of the clinical manifestations.
Client’s Locus of Control and Readiness to Learn
Patient exhibits an external locus of control in which she expresses her desire for more involvement of her daughters in her plan of care. Her readiness to learn is also evident since she seeks medical intervention when she realizes that her health is deteriorating.
ICD-10 Diagnoses/Client Problems
Possible ICD 10 diagnoses pertinent to this case scenario include but not limited to pulmonary emphysema coded as J43.0, COPD with acute exacerbation coded as J44.1, pneumonia coded as J18.9, unspecified obesity coded as E66.9 and tobacco use coded as Z72.0 (“Free 2016/17 ICD-10-CM Codes from ICD10Data.com”, 2016).
Lastly, possible client problems include leukoplakia of buccal mucosa coded as K13.21, shortness of breath coded as R06.02, Cough coded as R05 and Unspecified fever coded as R50.9 (“Free 2016/17 ICD-10-CM Codes from ICD10Data.com”, 2016).
Advanced Practice Nursing Intervention Plan
Of consideration to the management of this patient is her preference not to be admitted as she has expressed a desire of not being admitted before. Thus, it is logical if the patient can be treated as a client in the outpatient department since she is the custodian for her care in the patient-centered model. After checking the suitability of the treatment area, the nurse can begin to institute the various interventions.
One primary nursing intervention is ordering for diagnostic tests in collaboration with other health care professionals. Central to these diagnostics includesobtaining sputum for culture and sensitivity. The test will ascertain the causative agent for the COPD and guide the selection of agent-specific antibiotics apply to the scenario. Moreover, the nurse should order for a mammogram given the patient’s family history of breast cancer. Additionally, ordering for a bone density and checking for serum calcium and vitamin D are also important to this patient since she has a family history of osteoporosis.
Secondly, administering necessary medications to limit the severity of the symptoms is also crucial in the management of this patient. To begin with, as the nurse waits for culture and sensitivity results, he/she can administer a broad-spectrum antibiotic such as Ceftriaxone 1gm OD as he/she awaits the results of the test. After getting the results, the antibiotics can be modified to a more disease-agent particular type (Leekha, Terrell, & Edson, 2011).
Furthermore, the nurse has an obligation to manage the shortness of breath. Instrumental to this management are nursing interventions that enhance breathing. Such an intervention includes the use of inhalers like albuterol to open the airway and improve breathing. Since this inhaler has a potential to cause thrush development, use of steroid medications such as Symbicort to rinse the mouth is inevitable. Symbicort prevents further thrush development or progression for this case (Davidson & Innes, 2012).
That notwithstanding, the nurse must also address the nutritional needs since the patient has loss of appetite. Central to this, an administration of throat lozenges whenever necessary is inevitable. The lozenges will control the existent sore throats that the patient is experiencing. Moreover, administration of Nystatin solution is critical since it treats the oral thrush is present in the patient (Pappas et al., 2015). Clearly, interventions of this kind will promote nutrition for the patient since it will improve her appetite.
Besides, health education is of the essence in the management of this patient. For instance, teaching and encouraging the client to use purse-lipped breathing is also helpful in promoting respiration. Such is the case since the technique enables the patient to avert the challenge of shortness of breath that is common in COPD (Heslop et al., 2013). Furthermore, teaching her new bed-positioning techniques such as the use of pillows to raise the head will save her from shortness of breath since it will facilitate lung expansion compared to lying flat on the bed.
Additionally, a nurse must show reliance on other health care professionals in the full course of care from the initial interaction phase with the client and follow up care. One important intervention in this regard is seeking specialist consultation by referring the patient to a pulmonologist to ascertain the extent of COPD and conduct appropriate tests. Besides, consulting the nutritionist is also of the essence to appropriately counsel on the dietary practice that will help the patient lower her weight given the risk posed by high BMI, that she possesses (Hong, Lin, & Wan, 2016).
Finally, on follow-up, the nurse must assess for hypertension given the borderline hypertension that the patient possesses. Moreover, evaluating for depression is also necessary for this scenario. A case in point is the acceptance of the client that her stress levels have increased for a while due to her restriction indoors. Also, in the follow-up care, the nurse has a responsibility of identifying the necessary community resources that can be essential in the management of the patient. For instance, identifying the client’s support system (her daughters and church contacts) and directly involving them in the plan of care is beneficial(Vanderplasschen, Rapp, Pearce, Vandevelde, & Broekaert, 2013). Such is the case given its potential to reduce the depression levels, which are worsening because of loneliness.
Conclusion
In closure, indeed managing a patient requires a plan of care that will adequately meet all his/her needs. Failure to individualize the care plan can only result to ineffective management of patients. Thus, nurses must utilize a universal care plan if they are to avert this challenge.
References
Davidson, S. & Innes, J. (2012). Davidson’s essentials of medicine. London: Elsevier Health Sciences.
Free 2016/17 ICD-10-CM Codes from ICD10Data.com. (2016). Icd10data.com. Retrieved 28 October 2016, from http://www.icd10data.com/ICD10CM/Codes
Heslop, K., Newton, J., Baker, C., Burns, G., Carrick-Sen, D., & De Soyza, A. (2013). Effectiveness of cognitive behavioural therapy (CBT) interventions for anxiety in patients with chronic obstructive pulmonary disease (COPD) undertaken by respiratory nurses: the COPD CBT CARE study: (ISRCTN55206395). BMC Pulmonary Medicine, 13(1). http://dx.doi.org/10.1186/1471-2466-13-62
Hong, Q., Lin, H., & Wan, J. (2016). Chronic Bronchitis and Emphysema the Effect of Early Prevention and Nursing Observation. Chest, 149(4), A535. http://dx.doi.org/10.1016/j.chest.2016.02.558
Leekha, S., Terrell, C., & Edson, R. (2011). General Principles of Antimicrobial Therapy. Mayo Clinic Proceedings, 86(2), 156-167. http://dx.doi.org/10.4065/mcp.2010.0639
Pappas, P., Kauffman, C., Andes, D., Clancy, C., Marr, K., & Ostrosky-Zeichner, L. et al. (2015). Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis., civ933. http://dx.doi.org/10.1093/cid/civ933
Vanderplasschen, W., Rapp, R., Pearce, S., Vandevelde, S., & Broekaert, E. (2013). Mental Health, Recovery, and the Community. The Scientific World Journal, 2013, 1-3. http://dx.doi.org/10.1155/2013/926174
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