Nursing Health History - Assignment Example

Table of Contents Topic Page Health History Appendix Height and Weight Chart Appendix 2 Ecomap Appendix 3 Genogram Care Plan Nursing problem list Nursing Problem 1 Nursing Problem 2 Nursing Problem 3 Nursing Problem 4 Discharge Plan References Introduction Nursing health history is the first part and one of the most significant aspects in case studies. It is a systematic collection of subjective and objective data, ordering and step by step process including detailed information in determining client’s history, health status, and functional status and coping pattern. These vital information provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualised care and for the nursing process application as a whole (Waber, 2010). Using Gordon’s functional health pattern and Weber’s book (2010), the client G is hereby assessed. Profile of the client Client initials: G Date of birth: September 22, 2009 Age: 6 months and 27 days Sex: Male Ethnic origin: Caucasian Date of assessment: April 16, 2010 Reason for Admission: Mother says: “I bring my child to the hospital because he has running nose, cough, and shortness of breathing.” CHILDHOOD/ADULT ILLNESS  Measles  Hypertension  Mumps  Jaundice  Diabetes  Pneumonia  Ulcers  Tuberculosis  Cystitis  Chickenpox  STD  Hepatitis A and B  Rubella  Arthritis  Anaemia  Heart Disease  Tonsillitis  Infant Jaundice  Rheumatic Fever  Malaria  Scarlet Fever  Whooping Cough IMMUNIZATIONS x Diphtheria Smallpox x Measles Polio Influenza Mumps x Tetanus x Pertusis Rubella Tuberculin HiB According to the mother, the immunisations of the client are up to date as required by the Australian Childhood Immunisation. HOSPITALIZATIONS Date Age Reason 29/10/09 To 31/10/09 5 weeks old worsening cough, breathing difficulty, not feeding Accident The client has not met any sorts of accidents since he was born. Drug reaction The mother of the client states no known drug reaction. Allergies The mother of the client states no known allergies CURRENT PRESCRIBED MEDICATIONS Name Dosage Reason for Use Medication Description Paracetamol 127 mg po Fever control Antipyretic Salbutamol 4-6 puffs 6 hourly Cough, audible expiratory wheeze, shortness of breath Bronchodilator Development data The client is a six - month – old male who lives with his young mother and father in a single story house in a rural area near the school zone. He is the third child in the family. His mother is working part –time in a toy factory, while his father works full time in a factory. The mother of the client reported that at one month old, the client has uncoordinated random and reflexive movement. However, when the client was at this age, the mother reported that he experienced the same signs and symptoms of worsening cough especially at night-time, breathing difficulty, shortness of breath and running nose, and. During this time, the client was brought to the hospital for admission where he was diagnosed to have bronchiolitis. At four to five months old, the client is curious in his environment and coos. At five months old, the client transfers object from one hand to another, learns to play with his feet, moves his body, and stretches. At six months, the client imitates and babbles sounds and the mother reported that, the client began again to experience cough and shortness of breath The necessary developmental and physical observation was accomplished by the mother of the client for a normal development of a 6 month – old boy. Prenatal history The mother got married at 19 years of age, and she delivered her first baby at the age of 20. The mother is non diabetic, non hypertensive, and non asthmatic. The mother and father smoke 15 – 20 sticks of cigarettes per day. She is an occasional alcoholic beverage drinker, and had a history of smoking during high school days. Natal history The client is the third child in the family. The first two children are delivered through normal spontaneous delivery with no known complications. The client was also delivered vaginally with no pertinent complications reported. Birth weight was 3.2 kg. No known interventions were made during delivery. The mother of the client denied diagnosis of hypoglycaemia, hypothermia, anaemia, convulsions, respiratory distress, and jaundice. Post natal history The child was given immunisations since birth as required by the Australian Childhood Immunisation. The client was breastfed purely during the first three months and on the fourth month, vegetable and fruit juices are slowly introduced with no known adverse reactions or allergies noted. Health perception and health management pattern Child and Caregiver’s perception of health status (reason for admission) The client, G , is a six month and 27 days old male with a height of 71.5 weight 8.5 and a physical development appropriate to his age. The mother of the client rates his child’s health as 9/10 with chief complaints of cough that worsens at night, difficulty in breathing, running nose, and audible wheeze. In one year, the mother of the client would want to fully develop and strengthen the immune system of her client. The mother of the client stated that her child’s immunizations are up to date. Client’s mother states that she visits the GP when she feels the child is unwell. On the other hand, she admitted that she and the father of the child smoke 5 -10 sticks of tobacco per day making the child exposed to tobacco smoke while the parents are at home. The client is lying with his upper torso elevated in bed. He had not bathed for 2 days because his mother is so anxious with his condition. The client has crying spells, shortness of breath, and is not friendly. Salbutamol 6 puffs were administered as charted with good effect. Vital signs: Temperature 36.8 degrees Celsius, HR 169, RR 52, and oxygen saturation was 95% on the right arm in room air. Review of family history The client is positive for: Family history of wheezing, and shortness of breath Family history of cardiovascular disease Family history of high cholesterol level Family history of cancer of the lung Genogram: See Appendix 1 Environmental history and safety The client lives in a rural area, and both parents are smoker since 18 years old. His father works in a toy factor and his mother works part – time in the toy factory. Both parents consults 5 – 10 sticks of cigarettes per day, and this is considered as the major precipitating factor for the development of recurring lung problem of the client. Nutritional – metabolic health pattern Prior to admission, the following are the client’s fluid intake; however, this was decreased to around 50 percent because of exaggeration of bronchiolitis. Special Diet: 300 mls of Fresh fruit and vegetable juice Typical Home Daily Meal Pattern: The client consumes around 150 mls of milk every 5 hours, and 200 mls of water per day. Total Fluid Intake: Approximately 1250 ml/day The mother of the client states that the client is unable the usual amount of fruit juices and milk and the client had lost around 10% of his weight. Review anthropometric parameters Weight: 8.5 kg Height/Length: 71.5cm Head Circumference: 34.5 cm Temperature: 36.8 Pulse Rate: 169 per minute Respiratory Rate: 52 cycles per minute Growth charts See Appendix 2 Skin The mother of the client denies presence of birthmarks and history of allergies. The mother reported that the client had episodes of prickly heat and diaper rash especially on summertime. The mother denies applying sunscreen and lotion. On inspection, a mole at the right lower thigh was noted. An IV line is noted in the right upper arm. The skin is pink and non cyanotic. The texture of the skin is soft with no apparent lesions. No swelling or oedema noted. On palpation, skin is warm and dry with slight loss of skin turgor. Nails Fingernails: The mother denies that the client has history of infection, bleeding, and fissures in the fingernails. On inspection, fingernails were clean, smooth, and short. Fingernails were not excessively thick; however, the nail beds are hard, pink, immobile, and firm. The nails of the child were round with an evident 160 – degree angle between the base of the nail and skin. On palpation, the child was noted to have a good capillary refill of 2 seconds. No evidence of cyanosis or clubbing of nails was noted. Toenails: The mother denies that the client has history of infection, bleeding, and fissures in the toenails. On inspection, toenails were clean, smooth, and short. Toenails were excessively thick; however, the nail beds are hard, pink, immobile, and firm. On palpation, the child was noted to have a good capillary refill of 2 seconds. No evidence of cyanosis or clubbing of nails was noted. Head Client’s mother denies history of head injury. She also denies any history of lumps, and limitation of neck movement. On inspection, skull and face are round and symmetrical. Scalp is intact free from any lesions. Hair The client has a dark brown hair and the mother stated that the client’s hair becomes thicker over a period of six months. The mother denies history of soreness and itching scalp. The client’s hair was not trimmed ever since he is born. On inspection, the hair is clean. The scalp is noted to be smooth and firm, and no detectible lesion was noted. Oral cavity Lips are symmetrical, intact, pink and moist. Mucosa is pink and moist. Gums are pink and moist. Tongue is midline, pink and moist with no deficit in tongue strength. Uvula is midline. Elimination Health Pattern The mother of the client states that the usual pattern of bowel elimination of the child is 2 to 3 stools per day, and it is soft, and brown in colour. The mother denies episodes of constipation or loose watery stool. The mother of the client denies history of surgery of the bowel or diarrhoea. Skin integrity appears normal, with slight loss of skin turgor noted. Umbilicus is everted with no noticeable evidence of foul odour, redness, and discharges. The mother of the child states that the client’s usual urinary elimination pattern is 5 to 6 times daily (napy) coloured light yellow. The mother denies history of surgery in the bladder area. No medications were reportedly taken to assist elimination. Gastrointestinal The mother of the client denies any history of abdominal surgery, and infection. On inspection, the abdomen of the client is distended and asymmetrical. On auscultation, bruit was not detected, and bowel sounds were normoactive. Activity and Exercise Health Pattern Prior to hospitalisation, according to the mother, the client was observed to be an active and happy child. Pulmonary Function Prior to hospitalisation, the mother of the client reported that the client had one episode of difficulty of breathing, cough, and wheezing which had led to hospitalisation four months prior. The client was treated in the hospital with a diagnosis of bronchiolitis. The parents of the client are reportedly a smoker, and smokes cigarette even at home in front of their children. Last chest x – ray was done on admission. On inspection, the client has slight breathing difficulty, with respiratory rate of 52 cycles per minute. On auscultation, mild expiratory wheezing was heard in bilateral lung field. The mother of the client was encouraged to perform mild chest tapping in both lungs, and to place the client in two pillow orthopnea. Cardiovascular Function The mother of the client denies history of high blood pressure. The mother denied any history of surgery, heart disease, and swollen ankles. The mother denied that the client had bleeding tendencies or blood transfusion. The client is blood type B positive. Heart rate is 169 beats per minute. The client has a strong radial and apical pulse Musculoskeletal Function The muscle tone of the client is well developed. He can move his upper and lower extremities, with equal distribution of his body fat at the abdomen, and thighs. The reflexes are observed to be normal. On palpation, the client was noted to have warm peripheral extremities. Hearing The mother of the client denies history of deafness, use of hearing aids, having history of infection of the ear, and ear discharge. The mother cleans the outer ear of the client every other day or as needed. On inspection, the ears are equal in size and similar in shape. The skin has no nodules and is soft. The client turns toward the source whenever there a sound is made. Taste and smell The mother of the client denies history of allergies, trauma, nosebleeds, and snoring. Taste and smell sensation was not performed in a 6 month old child. Sexuality and reproductive health The mother of the client denies history of lumps around the breast, axilla, and testicle. On palpation, the client has no palpable masses and both scrotum are noted to be descended. Sleep – rest health pattern The usual time the client goes to bed is at 7:00pm and the usual rising time is at 6:00am. Prior to hospitalisation, the mother of the client has no difficulty putting him to sleep. However, the client is currently restless and cannot sleep soundly at night due to breathing difficulty. The mother reported that the client has crying spells and is irritable at night making them anxious during daytime. The client also experiences trembling of hands as one of the side effects of Salbutamol nebulisation. Sensory perceptual health pattern vision The mother of the client denies history of infection, disease, and surgery except that during 5 month old, the client was hospitalised due to complaints of chronic cough, shortness breath, and wheezing. Denied history of early onset of glaucoma and cataract. On examination, it was noted that the eyes are clear with moist surfaces and transparent corneas. Cranial nerves II, III, IV, and IV are not tested. Coping – Stress Tolerance The mother states that the client was born as a happy child. The child was always smiling, laughing, and cooing, and his behavior was typical of an infant baby boy until he had his first hospitalisation at 5- month old due to bronchiolitis. This event had brought major emotional and physical stress not only to the client himself but to his parents and siblings as well. Emotional and physical stress is evident in the client as restlessness, crying spells, and inability to sleep well at night. The mother also reported that the child is afraid of people wearing white outfit thinking that he will be hospitalised again. The mother also mentioned that the whole family is anxious of the client’s condition and recent hospitalisation. The stressor of the family members can be reduced by getting along with the community’s activities to gain social support from the neighborhood and the community group. There are coping mechanisms that will help the client and the family get through with the current stressful mechanism. These include: (1) Orient the mother to respond positively with the client’s current situation. The mother must learn how to relax and not to panic with recurrence of shortness of breathing. (2) Dealing with the emotional and physical dimensions by properly avoiding the emotional obsession in order to appropriately deal with the physical problem of the client (3) Resort to positive problem solving strategies by identifying the challenges encountered during the client’s handicap. (4) Teach the mother to cope anxiety with good positive outlook such as proper time management, relaxation techniques, exercise, and humour. Values and Beliefs Values and Beliefs of the Family The mother states that the client is important to the family. She stated that together with her husband, they worked very hard to provide their children not only material assets but the best future their children deserve to have. The mother relates that they are saving for an educational plan for their three children. They are also saving to have a comfortable home for their offspring. The mother further relates that they are devoted in their faith, and they believe that having a religious family is important to have successful children; however, she and her husband are addicted to cigarette smoking since teenage. The mother positively believes that with the current situation her youngest child is in, the couple will be able to get through with this bad habit for the sake of their child. Cognition and perception Mood and behaviour are appropriate to the age of the child. Other parameters were not tested in a 6 month old child. Roles and relationship The mother of the client stated that the client is a happy child. Every time his parents arrive home from work, he looks at them and smiles happily. He enjoys having his siblings and relatives around him. Ecomap – See appendix 3 Self concept The mother of the client described the client as sociable and friendly. The client makes eye contact with his parents and siblings and smiles every time he is with him until lately, when he begun to get sick, the client cries easily and is more attached to the mother than the rest of the family household. II. Nursing care plan for bronchiolitis 1- Ineffective pattern of breathing secondary to laboured breathing and decreased energy secondary to fatigue. 2- Fluid volume deficit related to poor fluid intake. 3- Sleep pattern disturbance related to respiratory disorder 4- Altered family processes related to child’s illness, hospitalization related to recurring condition of the client, treatment course, and the requirements for client’s home care. Nursing Problem 1- Ineffective breathing pattern secondary to laboured breathing and decreased energy secondary to fatigue. Manifested by: The child has laboured breathing because the client has cough that worsens at night-time. The client also has breathing difficulty, running nose, episodes of restlessness and audible expiratory wheeze. EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE The client’s respiratory rate will return to baseline, and the client will not experience laboured breathing The nurse will assess respiratory rate and depth of respiration and breath sound of the child every 2 – 4 hours. The nurse will monitor oxygen saturation through pulse oximetry and check vital signs every an hour. Breathing pattern changes occurs quickly and the reserve energy of the child is easily depleted. Rate and quality of air exchange of the can be quickly determined through proper assessment and monitoring of the child (Kozier, et al., 2004) The child’s oxygenation status will return to baseline which is from 92-99 The nurse will administer humidified oxygen via mask or hood as needed The nurse will administer bronchodilator 4 -6 puffs via spacer 6 hourly. Secretions are loosened and status of the client’s oxygenation is maintained through administration of humidified oxygen (Kozier, et al., 2004). Oxygenation is promptly increased and inflammation is decreased through the medications that act systemically and locally in the lung tissue (Wainwrigth, 2010) Evaluation of care given: Subjective data: The client’s mother states that “ my child looks better, he can breathe without difficulty” Objective data: Client can breathe without difficulty. Client appears more relaxed, comfortable and less restlessness. Respiratory rate is maintained at 28 cycles per minute. Oxygen saturation is maintained at 94 to 99 in room air. Assessment: Nursing interventions successful Plan: Continue with current nursing interventions as needed Nursing problem 2- Fluid volume deficit related to decreased oral intake. Manifested by: Dry mouth, lips, and lips, absence of tears, decreased intake and loss of skin turgor EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE The client will have adequate fluid and nutrient intake The nurse will administer I.V fluids and oral solution such as Infalyte at interval ordered by the Paediatrician. The nurse will encourage the client’s mother to continue breast feeding. The nurse will weigh the child daily. Infants are prone to fluid and electrolyte deficit s when they have respiratory illness because of rapid respiratory rate that prevent adequate fluid intake. Therefore, replacement therapy should be initiated (Perry, Hockenberry, Lowdermilk,& Wilson, 2010). It is evident that breastfed infant receive specific antibodies and cell-mediated immunologic factors that help protect against respiratory illness such as respiratory syncytial virus and pneumonia (Perry, Hockenberry, Lowdermilk,& Wilson, 2010). Increase the child’s immune system to fight against future illnesses (Kozier, et al., 2004). A daily weight can also measure hydration status (Perry, Hockenberry, Lowdermilk,& Wilson, 2010). Gain or loss of body fluid is reflected in changes of child’s weight (Kozier, et al., 2004). The client will achieve normal level of fluid volume within narrow safe limit The nurse will strictly monitor fluid intake and fluid output. The nurse will assess vital signs, skin turgor, mucous membranes, tongue and mental status. The nurse will monitor serum electrolytes as needed. It is crucial to monitor intake of fluids to insure correct volume concentration of electrolytes to be infused. It is also important to determine renal output to establish whether renal blood flow is sufficient to permit the addition of potassium to the I.V. fluids (Perry, Hockenberry, Lowdermilk,& Wilson, 2010). Assessing the hair, skin, lips, tongue and eyes will determine effectively signs of fluid volume deficit or overload because of rapid epithelial and mucosal tissue turnover (Kozier, et al., 2004). Levels of electrolytes should be checked frequently during fluid replacement therapy (Kozier, et al., 2004). Evaluation of care given: Subjective data: Client’s mother state that the child has become well and has started breastfeeding. The mother also reported that her child’s nappy is wet. Objective data: Client is tolerating replacement therapy and his input and output documented in fluid balance chart. Client’s vital signs, skin turgor, mucous membranes are showing improvements in hydration from physical examination Assessment: Client has been adequately hydrated through I.V replacement therapy and oral fluids as evident by physical examination. Plan: I.V fluid was disconnected as the child tolerated oral intake and continue with current nursing interventions as needed Nursing problem 3- Sleep pattern disturbance related to respiratory disorder. Manifested by: Breathing difficulty, fatigue, restlessness secondary to lack of sleep EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE The client will maintain an effective sleeping pattern 11 to 12 hours a day. The nurse will monitor periods of wakefulness and sleep pattern. The nurse will evaluate contribution of environmental stimuli to disturbed sleep pattern. To determine the presence or lack of an effective sleep and wake cycle. Consequently, corrective actions can be planned (Hoban and Chervin, 2004; Kozier, et al., 2004). Infants are hyperactive and easily stimulated. External noise and light may contribute to the infant’s hyperactive state and inability to maintain a more normal sleep cycle (Hoban and Chervin, 2004; Kozier, et al., 2004). The client’s mother will participate in caring for the child The nurse will teach the client’s mother about infant sleep needs. The nurse teaches the mother to promote comfort and relaxation The nurse will teach the mother promote comfort and relaxation. The infant should sleep when he is dry and comfortable with soft clothing and dry nappies To increase the awareness on the appropriate sleep behaviour in the infant to help ensure that the mother recognizes sleep alteration in her infant and implement actions to enhance sleep (Hoban and Chervin, 2004; Kozier, et al., 2004). To calm the infant and help ensure adequate sleep (Hoban and Chervin, 2004; Kozier, et al., 2004). Evaluation of care given: Subjective data The mother of the client reports that the client had maintained enough sleep from the second day Objective data The client is active and exhibits a good affect Assessment The client is active and exhibits a good affect Plan Encourage the parents to continue a good and effective sleeping pattern of the client. Nursing problem 4- Altered family processes related to child’s illness, hospitalization related to recurring condition of the client, treatment course, and the requirements for client’s home care. Manifested by: Apprehension, dread, anxiety, foreboding, uneasiness associated to unidentified source of danger that is anticipated. EXPECTED OUTCOME NURSING INTERVENTION SCIENTIFIC RATIONALE To decrease anxiety and fear among parents and child as visible as they feel more secure in an environment in the hospital. The nurse will assure the mother of the client that the she will stay with her child when the client is dyspenic. The nurse will encourage the parents to participate in the care of the clients by asking them to incorporate care plan in the routine feeding and sleeping at home Having the caregiver stay while the child is dyspneic assures the mother that her child is safe (Kozier, Erb, Berman, & Snyder, 2000). This can reduce the anxiety of the child and parents and decrease need for sedation (Perry, Hockenberry, Lowdermilk,& Wilson, 2010). The parents will demonstrate an understanding of home care instructions of bronchiolitis. The nurse will assess the parents to understand the child’s status, treatment given and home care The nurse will encourage the parents to ask questions and express concerns Helping parents understand the child’s condition post hospitalization is necessary for them to tolerate d support themselves from fear and anxiety. (Perry, Hockenberry, Lowdermilk,& Wilson, 2010). Encouraging the parent to write down queries provides reassurance and helps to reduce anxiety (Perry, Hockenberry, Lowdermilk,& Wilson, 2010). Evaluation of care given: Subjective Data: The mother verbalises that, “my child is doing well, and he can sleep well at night.” Objective data: The mother and the client are friendly, smiling and approachable. No traces of anxiety and fear are observed in their faces. Assessment: The client is active and exhibits a good affect Plan: Encourage the mother and child to socialize in their community Discharge plan Prior to discharge, the mother and the family of the client are instructed to reduce future readmission with serious complications Facility: Swan district hospital Date Admitted: April 16, 2010 Date Discharged: April 20, 2010 Principal Diagnosis: Bronchiolitis Discharge Medication: Medication Dose/Frequency Paracetamol 127 mg every 4 hours for fever and pain Salbutamol Nebulisation 1 nebule every 6 hours as needed The mother of the client was given prescription for fever and analgesia, discharge summary to GP. Follow – up appointment to see the client’s Paediatrician two weeks after the discharge. Home care advice and what to expect after discharge 1. Written and oral instruction as well as education about upper respiratory infections, information leaflets 2. Encourage the mother of the client continued high liquid diet 3. Advise client’s mother and father to refrain or stop smoking 4. Encourage mother to perform light chest tapping Complications To be aware of increased respiratory rate, difficulty in breathing, nausea, vomiting, weight loss, and decrease appetite REFERENCES 1. Carpenito, L. J. (2002). Nursing Diagnosis: Application to Clinical Practice (9th ed.). Philadelphia: Lippincott Williams & Wilkins 2. Hoban, T. and Chervin, R. 2004. Tremblay, R., Barr, R., Peters, R. Eds. Encyclopedia on Early Childhood Development (2004: 1-5). Quebec: Centre of Excellence for Early Childhood Development 3. Kozier, B., Erb, G., Berman, A.,& Snyder, S. ( 2004). Fundamentals of Nursing. 7th edition. New Jersey: Prentice Hall. 4. Perry, S, E, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child nursing care. (4rd ed.). St Louis: Mosby. 5. Weber, J. (2010). Health Assessment in Nursing (4Prd Ped.). Philadelphia: Lippincott Williams & Wilkins. Read More