Assessment and Management of Clinical Medical Problems - Admission/Application Essay Example

?NURS 401 NURSING CARE PLAN Part ____________________________________ submitted:______________ Patient Initials:_H.S.____Age/Sex_48 yo/ Male Medical Diagnosis:_Diverticulitis________ I. Etiology and Pathophysiology: Diverticulitis is an acute inflammation of a diverticulum resulting from an obstruction by fecal matter. Initially, the walls of the bowel form saclike outpouchings called diverticulum because of the compounded effect of high intraluminal bowel pressure (HS usually lifts heavy objects at work), low volume in the colon, and decreased muscle strength of the colon walls. Smoking has also been linked to diverticulitis as it suppresses the immune system that would allow the proliferation of bacteria in the diverticula. Areas in the colon where nerves, arteries, and other connective tissue sheaths penetrate the inner circular muscle coat, focal weaknesses of the entire length of the colon are formed. These areas are prone to herniate and produce diverticula. In most cases, the inflamed diverticulum ultimately results into abscess formation (Smeltzer & Bare, 2006, p. 1037). Consequently, fecal matter and bacteria invading these outpouchings can cause local infection that can proceed into systemic infection as the condition progresses. Tissue edema and local irritation cause spasticity of the entire colon and disrupt its normal function. If left uncontrolled, the inflamed diverticulum can perforate and extrude fecal matter and bacteria to the surrounding organs in the abdominal cavity. Massive bleeding can also result when large blood vessels are disrupted. II. Clinical Manifestations (Signs & Symptoms): Diverticular diseases frequently do not cause distinct clinical features, and patients often only have a history of chronic constipation. In fact, lesions are most often discovered incidentally. Despite the ambiguity of clinical manifestations, symptomatic diverticulitis present intermittent cramping, continuous lower abdominal discomfort, distention, and a sensation of never being able to completely empty the rectum. Patients sometimes experience alternating constipation and diarrhea. Occasionally there may be minimal chronic or intermittent blood loss, or, in extremely rare cases, massive hemorrhage. With systemic infection, patients experience nausea, vomiting, a low-grade fever, and an abrupt onset of crampy pain. Longitudinal studies have shown that diverticula can regress early in their development or, more commonly, become more numerous and prominent over time (Smeltzer & Bare, 2006, p. 1038). III. Treatment and Nursing Management: Surgical management of H.S. includes a bowel resection and colon reversal. Nursing interventions focus primarily on preventing infection by proper wound care and monitoring for signs of infection, routinely changing urinary catheter, and ensuring drains do not touch the floor and kept clean. H.S. response to pain medication as ordered by physician should be appropriately recorded. IV: Diagnostic Studies/Lab analysis: Essentially normal and results indicate H.S. is allowed to undergo operation. Discharge Planning and Client Teaching Continue medications as prescribed by the physician. HS and his caregiver should be taught of proper wound care and should be asked for a return demonstration to ensure complete understanding. NURS 401 NURSING CARE PLAN Growth and Development According to Erickson Stage: 7 Crisis: Generativity vs Stagnation (Videbect, 2007, p. 53) I. Describe your patient’s ability to achieve growth and development tasks. Prior to admission, the H.S. was performing his role and job as an auto mechanic and a baseball coach. These activities helped him achieve the sense of creativity, productivity, and fulfillment that he is able to help establish the next generation. Specifically, his job as an auto mechanic enabled him to be a productive member of the society and thus achieve generativity, as indicated by Erikson’s psychosocial stages. Furthermore, his career as a baseball coach gave him the opportunity to teach and rear children, so as to lead them and assume responsibility at a certain degree for their growth in the field of sports. II. How is this ability affected by the underlying disease process and/or the current admission? H.S.’s condition has strong implications on his ability to achieve the psychosocial task of being creative and productive and being able to help establish the next generation. In fact, the condition may hamper H.S.’s work as he will not be allowed to perform heavy tasks while still recovering from the operation. With the limitations posed by his condition, a sense of stagnation may overwhelm him that would eventually cause physical and psychological invalidism. III. List nursing actions to assist your client in meeting their growth and developmental needs. 1. Assess H.S.’s degree of coping to condition. 2. Maintain therapeutic communication such as using empathy and active listening. 3. Encourage expression of feelings but set limit in maladaptive behavior. 4. Keep H.S. informed of his condition including his possible limitations of activity and answer his questions appropriately. 5. Encourage open communication with the SO and involve them in the care of the patient. IV: List in priority order all relevant nursing diagnoses for your patient. Acute pain related to inflamed bowel. Risk for deficient fluid volume related to drains and effect of hypermetabolic state. Impaired tissue and skin integrity: Gastrointestinal related to surgery. Morgan State University NURS 401 – Nursing Process and Health Assessments Nursing Care Plan Part 2 Assessment Data Nursing Diagnosis (according to NANDA) Nursing Actions List in order of priority. Label aspect of care. Patient Non-Verbal State the rationale for each nursing action. Cite reference and page number. Evaluation Evaluate each nursing action. HS, 48 yo, diagnosed as having Diverticulitis and has recently undergone bowel resection and colon reversal. Drains were also placed on 10/30/12. Subjective: “My abdomen seems cramping all this time,” as verbalized. Objective: Pain score of 8 in a scale of 10 Guarding position noted Tensed abdominal muscles noted Vital signs BP 120/60 mmHg Resp 20 cpm Pulse 60 bpm O2 sat 98 Acute pain related to bowel inflammation and surgical trauma to tissues. Assess level of pain in a regular basis and as necessary. (Physiologic) Administer pain medications as ordered by physician. (Physiologic) Demonstrate and encourage performance of nonpharmacological techniques such as relaxation and breathing techniques to lessen pain experience. (Learning) Encourage to verbalize feelings about situation. (Psychosocial) Pain is managed easier when it is milder (Ignatavicius & Workman, 2006, pp 68, 72). For severe pain, analgesics are required on a regular basis to prevent aggravation and prolongation of suffering. This type of pain does not respond to relaxation techniques that well (Ignatavicius & Workman, 2006, pp 68, 72). Relaxation techniques are effective interventions to lessen the demand for pain and prevent overdose of analgesics (Ignatavicius & Workman, 2006, pp 68, 72). Verbalization of feeling help ease the psychosocial burden of illness (Stuart & Laraia, 2005, pp. 30-34). Pain was assessed every 2 hours and every patient contact as seen necessary. Pain medications were ordered by physician and administered as scheduled. Pain score reduced from 8 to 4 within the eight- hour time frame. H.S. performed relaxation and breathing exercises as demonstrated and is willing to perform on a regular basis. H.S. was emotional in dealing with current condition. Expected Outcome: After 8 hours, H.S. will have relief and adequate control of pain. Pain score will be 4 in a scale of 10. Evaluate each expected outcome: Goal met. After 8 hours, H.S. experienced relief from pain and verbalizes effective ways to lessen pain like relaxation and breathing techniques. Pain scale is 4. NURS 401 NURSING CARE PLAN Part 1 Student Name:____________________________________ Date submitted:______________ Patient Initials:_J.T..____Age/Sex_58 yo/ Male Medical Diagnosis:_Empyema ________ I. Etiology and Pathophysiology: Empyema is the accumulation of purulent material in the pleural space. Normally, the pleural cavity contains a thin sterile fluid that keeps the friction low between visceral and parietal walls of the lungs. In empyema, this fluid becomes thicker and fibropurulent as it is invaded by bacterial or fungal microorganisms. Usually, these microorganisms come from an intrapulmonary source such as an underlying pulmonary infection. In other instances, the causative agents may come from other parts of the body and traveled only through the lymphatic or vascular routes (Smeltzer & Bare, 2006, p. 541). II. Clinical Manifestations (Signs & Symptoms): Patients with empyema usually present an acute illness clinically indistinguishable from other respiratory infection. Signs and symptoms include productive coughing, fever, night sweats, and pain especially upon inhalation, anorexia, and weight loss. Laboratory studies in empyema demonstrate loculated, yellow-green, creamy pus composed of masses of neutrophils admixed with other leukocytes. On the other hand, in patients who have started antimicrobial therapy, the signs and symptoms may not be clinically obvious (Smeltzer & Bare, 2006, p. 542) III. Treatment and Nursing Management: The goal of management of empyema is to evacuate the pleural cavity of the accumulated purulent exudates that is causing the lungs to expand poorly. This can be done gradually by needle aspiration or a tube thoracostomy. In other instances when the exudates form a cavity surrounded by fibroids, rib resection may be instituted to remove the thickened pleura, purulent debris, and the diseased pulmonary tissue if necessary. The role of the nurse in the management is to ensure that the patient maintains a patent airway and effective respirations by frequently monitoring the patient even after minor surgical intervention. If the patient is to have a thoracostomy tube, appropriate care must be maintained to prevent re-infection. Breathing and coughing exercises are also effective interventions that can be demonstrated by the nurse to ensure early lung expansion. Medications needed to re- sterilize the pleura should be given as ordered which may take 4 to 6 weeks. IV: Diagnostic Studies/Lab analysis: WBC Count- 15 x 103/mm3 (N- 3.54–9.06 x 103/mm3) – Implies underlying infection Differential blood count Results Normal range Implications Neutrophils 0.85 0.40–0.70 Implies bacterial infection Bands 0 0.0–0.05 Within normal range Lymphocytes 0.6 0.20–0.50 Implies bacterial infection Monocytes 0.04 0.04–0.08 Within normal range Discharge Planning and Client Teaching Continue medications as prescribed by the physician. If the patient has to return home with a thoracostomy tube, caregivers at home and the patient himself should be taught on its proper care. Breathing and coughing exercises should be regularly performed. NURS 401 NURSING CARE PLAN Growth and Development According to Erickson Stage: 7 Crisis: Generativity vs Stagnation (Videbect, 2007, p. 53) I. Describe your patient’s ability to achieve growth and development tasks. Prior to admission, J.T. is able to perform his job as a marketing supervisor and enthusiastically teaches his associates and junior marketing team of effective marketing strategies. He enjoys teaching younger entrepreneurs and focuses on them meticulously to ensure that projects were done smoothly and well- coordinated. Furthermore, J.T. is also one of the church leaders in his area and is a father of two sons, now both married and successful in their career. II. How is this ability affected by the underlying disease process and/or the current admission? J.T. tries to remain optimistic despite his condition and hopes for a faster recovery. However, the severity and extent of his condition may actually prolong his stay in the hospital as monitoring of respiratory function as well as antibiotics should be performed first in the hospital. In addition, there is a possibility of having a tube thoracostomy insertion and this would ultimately affect the JT’s performance of his activities of daily living. III. List nursing actions to assist your client in meeting their growth and developmental needs. 1. Monitor the JT’s stage of coping for his condition and its associated possible disability. 2. Determine the JT’s level of understanding of his condition and supplement or correct some information as necessary. 3. Maintain therapeutic communication such as using empathy and active listening. 4. Encourage open communication with the SO and involve them in the care of JT. IV. List in priority order all relevant nursing diagnoses for your patient. Ineffective airway clearance related to airway obstruction secondary to the buildup of secretions Acute pain related to inflammation of the pulmonary tissues secondary to disease process Risk for ineffective breathing pattern related to pain upon each inhalation Morgan State University NURS 401 – Nursing Process and Health Assessments Nursing Care Plan Part 2 Assessment Data Nursing Diagnosis (according to NANDA) Nursing Actions List in order of priority. Label aspect of care. Patient Non-Verbal State the rationale for each nursing action. Cite reference and page number. Evaluation Evaluate each nursing action. J.T., 58 y.o, presented with productive cough and difficulty of breathing. Admitting diagnosis is Empyema. Subjective: “My throat seems full of phlegm it’s hard for me to breath,” as verbalized. Objective: Crackles heard at lung fields Use of accessory muscles of breathing noted Frequent coughing with copious phlegm noted Vital signs BP 130/70 Resp 30 Pulse 50 O2 89 Ineffective airway clearance related to airway obstruction secondary to the buildup of secretions Assess and monitor respiratory rate and rhythm regularly. (Physiologic) Administer medications as ordered by physician. (Physiologic) Demonstrate the proper techniques of deep breathing and coughing exercises and encourage returning the demonstration. (Learning) Encourage verbalization of feelings about current condition. (Psychosocial) Continuous monitoring can prevent hypoxia associated with increased bronchopulmonary secretions and ensure early intervention in case such complications arise (Lewis, Heitkemper & Dirksen, 2004, p. 675). Medications to enhance airway patency and promote ease of breathing should be given as scheduled to maintain efficacy and prevent unnecessary suffering (Lewis, Heitkemper & Dirksen, 2004, p. 675). Coughing and deep breathing exercises are effective interventions to extrude accumulated secretions in the bronchopulmonary passages. Return demonstration ensures learning (Lewis, Heitkemper & Dirksen, 2004, p. 675). Hospital admission pose danger to self- esteem and needs appropriate intervention like encouraging verbalization to ease the psychological stress (Stuart & Laraia, 2005, pp. 30-34). JT was monitored in an hourly basis to prevent complications like hypoxia associated with problems in airway patency. Medications were given as ordered and as scheduled. JT was willing to perform the deep breathing and coughing exercises and responded to the intervention well. JT was at first hesitant but later on was willing to share his feelings about being hospitalized. Expected Outcome: After 8 hours, JT will learn proper techniques of deep breathing and coughing exercises. Evaluate each expected outcome: Goal met. JT learned the proper techniques of deep breathing and coughing exercise to alleviate his difficulty of breathing. References Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 68, 72). Philadelphia: W.B. Saunders. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 675). St. Louis: Mosby. Smeltzer, S.C. & Bare, B.G. (2006). Brunner and Suddarth's textbook of medical-surgical nursing, 12th ed. Philadelphia, PA: Lippincott Williams & Wilkins. Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Videbect, SL. (2007). Psychiatric mental health nursing (4th ed). New York: Lippincott Williams and Wilkins. Read More