Nursing Care Plan for Glady - Case Study Example

Care plan for Glady A 60-year old widow and mother of three adult daughters, Glady has sought medical attention on account the chest pain that has been bothering her already for seven days. Subjecting her to physical examinations and interviewing her on her medical history and health status, it has been established that her reason for coming for medical check-up is indeed just the tip of the iceberg, so to speak. There are other medical issues that beset her and that she needs to address and/or be cured of at least starting from the time she is admitted to the hospital for her chest pain. The following is a nursing care plan for Glady. More than a blueprint of how she would go on day by day with her medical conditions, beginning from the time she is admitted to hospital to immediately address her chest pain, it is also about her commitment – or, more precisely, those to which she must commit herself to with the aid of health professional(s) – to consistently manage her health. And, while this care plan zeroes in on Glady’s chest pain and, in the process, simply makes the connections between the pain for which she has sought medical care and other health issues that she is found to have and afflicted with, a careful scrutiny of her other maladies is going to be effected. Assessment Glady complains of chest pain, which accordingly begins in the left parasternal area and creeps towards the neck. She observes that the pain is increasing in frequency and severity. She reports, too, that although her chest pain is not accompanied by giddiness and palpitations, it is making her feel tired and uncomfortable. When asked what could have occasioned her pain, she answered that it attacks when she’s in state of exertion. At the time she was examined, her blood pressure was 168/98 – indicative of the second stage of high blood pressure (HBP) (see Simon, 2002) – and her pulse rate is 90, which is two notches higher than the normal pulse rate of women (see Vital Signs, [n.d.]). She admits, too, of her being part of a family with history of ASCVD. She was in fact diagnosed with hypertension (HTN) three years ago, for which she was prescribed a medicine (the brand name she can no longer recall and) which she stopped taking after she suffered from drowsiness. It is on this account that Glady is adjudged by the doctors for hospitalization. Likewise, Glady reports shortness of breathing as her chest pain occurs. But, she tells of no dyspnea as she works or exerts an effort (exertional dyspnea). She also accounts no inability to breathe easily unless she sits up straight or stands erect (orthopnea). Dyspnea in the middle of the night (paroxysmal nocturnal dyspnea) is also foreign to her. Likewise, she has had no history of lung disease (see Lechtzin, 2009). Auscultation was able to trace a bruit, or an unusual sound that blood makes when it rushes past an obstruction in an artery, in Glady’s right para-umbilical area. Crackles were also heard in her lung bases bilaterally. It was determined that its point of maximum impulse is the fifth inter-costal space at the mid-clavicular line; a grade 2/6 systolic decrescendo murmur is audible best at the second right inter-costal space, radiating to the neck; and a third sound is heard at the apex. In addition, Glady notes of burning epigastric pain at least a couple of times per month – primarily at night. She also discloses that she has had a history of peptic ulcer, which she contacted eight years ago. For medication, she took Cimetidine (brand name: Tagamet) for three months after her peptic ulcer was diagnosed. To ease her lumbosacral back pain, which she associates with exertion or any strenuous activity such as when she tends her garden, Glady takes Tylenol. Aside from her painful sensation on her lower back, she complains of no other muscle pain. She admits, too, that she’s resorting to Advil, an over-the-counter (OTC) non-steroidal analgesic for headache. As she was physically examined, cystic changes were noted in her breasts bilaterally. However, there were no mass or nipple discharges. Finally, she shared to her attending physician that she has had history of penicillin allergy. Nursing diagnosis Primarily, Glady suffers from a radiating chest pain and/or discomfort, which suggests of ischemic cardiac origin. The indications for this diagnosis are very clear. She has FH of ASCVD and her HTN has just begun – indicating the development of coronary disease. Now, related to her coronary problem, she is likewise found to have ineffective airway clearance. Too, she is diagnosed for risk for prone behavior related to lack of knowledge about – particularly – HTN. Further, she is found to have a “lumpy” breast and she experiences pain associated with chemical burn of gastric mucosa. Outcome identification Given the preceding assessment and diagnoses, the eventual nursing interventions are expected to focus for the most part on Glady’s chest pain and would touch on her secondary medical concerns. As she is going to be admitted to the hospital, at least within a couple-of-days time, Glady would report a decrease – to be determined by a scale – in frequency, severity and duration of her chest pain. At the same time, she is expected to demonstrate relief of pain as evidenced by stable vital signs, the lessening or disappearance of the abdominal bruit, lessening of her gastric pain and the absence of her restlessness and discomfort. Concomitantly, Glady is expected to manifest behavior that will improve her airway clearance. In addition, she will verbalize a correct understanding of the HTN process and treatment regimen. With her understanding of these, she is expected to demonstrate behavior that would surely clear her away from factors that advance her hypertensive state. She would be relieved of anxiety, too, as the condition of her breast is explained to her. Nursing interventions To significantly lessen the severity, frequency and duration of Glady’s chest pain, she would be understandably extended multiple of nursing interventions. Primary of these interventions is the assessment for her signs and symptoms of pain and discomfort. Her verbalization of pain and body language – such as grimacing, rubbing her neck, clutching her neck, restlessness, etc. – together with diaphoresis, increased blood pressure (BP) and even tachycardia are going to be noted. (Pain that originates from her gastric area needs to be monitored, too.) As the preceding signs and symptoms are relative by nature, her laboratory and serial ECG results are objective monitors of Glady’s condition. It is also very important that she’s given relief of her pain and/or discomfort. As ordered by the physician, she may be administered nitroglycerin. Oxygen therapy may also be ordered for her to increase the myocardial oxygen supply. Should her pain or discomfort be unrelieved by rest and nitroglycerin (within fifteen to twenty minutes), Glady may need to be administered a narcotic (opiod) analgesic such as morphine sulfate – as ordered – intravenously. Relief of her pain and/or discomfort may also be effect by non-pharmacologic measures. Glady may be put on bed rest in a semi- to high Fowler’s position. She is to be brought on to change her position every now and then. She’s to be taught relaxation techniques. Her environment is going to be kept comfortable and restful. It is also important that she is provided with emotional support. And anticipating that she would eventually be discharged from the hospital, she is to be given taught – as part of her discharge planning – about her medication regimen, dietary requirements, and ways to minimize events and/or activities that precipitate her chest pain attacks. The supplemental oxygen supply to the patient (to augment her myocardial oxygen provision) would actually bring her relief from her ineffective airway clearance too. Signs of dyspnea need to be monitored and reported, too. The nurse, in auscultating breathing sounds, takes note of adventitious sounds like wheezes, crackles and rhonci (see Lechtzin, 2009) – as these may be symptoms, too, of allergy to medications especially to penicillin (Vijay, 2010). Aside from the keeping her as she rests in semi- or high Fowler position, which effectively keeps her head elevated from the bead, she may be made to lean on over-bed table or sit on the edge of the bed should she find it hard to breathe (see Lechtzin, 2009). Besides keeping her environment comfortable and restful, it should also be kept free from dust, smoke, feather pillows, etc. Reduction of stress and anxiety as much as possible is a proven respite for anyone with this condition. Too, increased hydration is encouraged – in particular, warm or tepid liquid is recommended. As part of her discharge planning, it would help her in the long haul if she is taught abdominal or pursed lip breathing exercise. To assist Glady cope with the onset of her HTN, nursing interventions would primarily take the form of education (see Your Guide to Lowering High Blood Pressure, [n.d.]) . She needs to be reminded of the limits of desired BP considering her situation, together with the effects on her heart, blood vessels, kidney and brain by HTN. She will likewise be assisted in identifying modifiable risk factors like diet that is high in sodium, saturated fats and cholesterol. She is also to be encouraged to decrease or completely eliminate caffeine – i.e., tea, coffee, cola and chocolate. Reinforcing the importance of adhering to treatment regimen and follow up appointments will also be made. The patient is long past her menopause, which exposes her to vulnerabilities as outcomes of hormones produced by the ovaries. As lumpy breasts normally have no symptoms, mammogram, ultrasound, or both may be done on her to more fully ascertain her breast condition. She may need to be taught to do self-examination of her breast to keep track of the development of its condition (see Wechter). Practical suggestions will also be made – such as frequently changing one’s position and exercising one’s legs when lying down, and ensuring that daily rest periods are regularly had (which is expected to relieve her, too, of her lumbosacral back pains). It may also help to provide Glady information on available community resources and support systems that support and/or complement HTN patients’ effort to change their lifestyle. Rationale Assessment of the signs and symptoms of pain and discomfort by Glady, especially those particularly associated with her chest pain and ineffective airway clearance, is necessitated by the need for baseline data, which is expectedly important to more fully determine her health status and to inform the succeeding nursing interventions for her. Too, it is important to keep track of the specific signs and symptoms as these would tell of “bigger” medical problems – such as her BP may rise or fall or tachycardia develops and may even be sustained if her cardiac output is compromised. Signs of allergies need to be carefully monitored, too, as the patient has indicated that she has had a history of penicillin allergy (see Vijay, 2010). Diagnostic studies such as ECG, stress test, serum lipids, and cardiac enzymes are likely to identity more comprehensively her cardiac conditions. Some degree of bronchospasm is present with obstruction in airway, but may or may not be manifested in adventitious breathing sounds. Relief of pain and/or discomfort is brought about by supplemental oxygen, which addresses both the need for additional oxygen supply for myocardial activities and the easing of ineffective airway clearance. Semi- or high Fowler’s position works, too, to decrease myocardial workload and to relieve shortness of breath as it facilitates respiratory function by use of gravity, as position changes and leg exercises decrease peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing (see Lechtzin, 2009). Positioning while at rest will also relieve her of her back pain. Medications that are given to patients such diagnosis as chest pain associated with ischemic origin (i.e., angina pectoris) promote vasodilation (e.g., Nitroglycerin), reduce cardiac workload (e.g., beta blockers), reduce coronary artery spasms (e.g., calcium channel blockers) and relieve pain (morphine sulfate). Intramuscular injection of narcotic analgesic is poorly absorbed if tissue perfusion is decreased and, in effect, elevates some serum enzyme levels that make assessment of myocardial damage more difficult – thus, the option to intravenously administer the medicine(s). analgesic and morphine sulfate may likewise relieve her of her gastric pain. Providing Glady a comfortable and restful environment is required by the fact that mental and emotional stress increases myocardial workload. That her environment also must be free from precipitators of allergic type of respiratory reactions is obliged by the fact that these can trigger or exacerbate onset of acute episode of dyspnea. Emotional support reduces patient’s anxiety, too. Breathing exercises provide patients with means to cope or control dyspnea and reduce air tapping. Hydration helps lessen the viscosity of secretions – hence, facilitating expectoration; and warm liquid may lessen bronchospasm. Pre-discharged education of the patient is always helpful. Educating Glady on her diet would consist of telling her that light meal actually decreases the risk of myocardial attacks as myocardial workload is lessened. Proper use of medication along with its expected side effects – e.g. Nitroglyceriin – needs to be taught to the patient. She should also be encouraged to avoid stressful events, over-exertion and to have a regular exercise program as well as maintain low fat, low cholesterol dies and small but frequent meals (which is suggested also for patients with gastric problem). Education as a key nursing intervention for the onset of Glady’s HTN consists of providing basis for understanding elevations of BP and clarification of misconceptions and understanding that high BP can exist without symptoms or even when feeling well. There are risk factors that are known to contribute to hypertension; and, consciousness on them is a plus antihypertensive factor. Further, the experience of medical practitioners tells that lack of cooperation (by the patient) is common reason for failure of HTN therapy. Too, it has been established that two years of moderate low salt diet may be sufficient to control mild hypertension. Caffeine is cardiac stimulant and may adversely affect cardiac function. Alternating rest and activity increases tolerance to activity progression. Finally, community resources like health center programs and check-ups are valuable support mechanisms in battling HTN (see Your Guide to Lowering High Blood Pressure, [n.d.]). It needs to be pointed out in here, too, that abdominal bruit – revealed by auscultation – to the right or left of the umbilicus midline or in the flanks must have been occasioned by the major cause of the patient’s chest pain. As such, when the chest pain is addressed, the abdominal bruit is brought to an end (see Nursing Diagnosis HTN, 2010). The same may be said of Glady’s systolic murmurs. The patient’s systolic murmurs – which must be functional in nature – occur accompanied by a high cardiac output states. And, as these murmurs are regurgitant murmurs – that is, created when blood flows from a high-pressure “donor” chamber to a low-pressure “recipient” chamber, they indicate heart disease (see Alpert 2000). The interventions related to Glady’s breast conditions are meant to allay fears or anxieties that may spring out of the fibrocystic lump in her mammary glands. Normally, the prognosis of this medical condition is quite optimistic as it raises no increased risk of cancer (see Wechter 2009). Evaluation The evaluation of this nursing care plan is going to be facilitated by a mere review of the goals that were set at the inception. Thus, this care plan is rendered effective when, in two days time, the chest pain by Glady is reduced in frequency, severity and duration; if she imbibes behavior that improves her airway clearance, and steers her away from factors or activities that advance her HTN state; if she learns about HTN process and its ensuing treatment regimen; and when she shows signs of relief from anxiety despite her knowing her medical conditions. An evaluation of this nursing care plan would have to begin with a recognition that it is merely for a couple of days, or until Glady is discharged from the hospital. That is, another care plan is going to be devised when she returns for medical check-up, or when her disease(s) relapse. For now, the nursing interventions meet her where she is. While medications are prescribed and medical tests were/are run on her, she is undoubtedly right at the initial phase of her sickness. And, at the this stage, the nursing interventions are meant to empower her so as to make her able to behave in such a way that she is able to manage her health conditions. References: Alpert, M. (1990). Systolic murmurs. Clinical Methods. Available at: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A746 [Accessed 18 May 2010]. Lechtzin, N. (2009). Dyspnea. The Merck Manual for Health Professionals. Available at: http://www.merck.com/mmpe/sec05/ch045/ch045d.html [Accessed 20 May, 2010]. Nursing diagnosis hypertension, 2010. Available at: http://www.lifenurses.com/nursing-diagnosis-hypertension/ [Accessed 16 May 2010]. Simon, G. (2002). Why do hypertensives suffer stroke? Pathophysiologic considerations. Medscape. Available at: http://www.medscape.com/viewarticle/443219_3 [Accessed 18 May 2010]. Vijay Kumar Soni. (2010). Penicillin allergy: are you allergic to penicillin? Studyhealth.com. Available at: http://www.steadyhealth.com/articles/Penicillin_Allergy__Are_You_Allergic_to_Penicillin__a1164.html [Accessed 22 May 2010]. Vital signs, [n.d.]. Rush University Medical Center. Available at: http://www.rush.edu/rumc/page-P06792.html [Accessed 18 May 2010]. Wechter, D.G. (2009). Fibrocystic breast disease. MedlinePlus. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000912.htm [Accessed 22 May 2010]. Your guide to lowering high blood pressure, [n.d.]. Available at: http://www.nhlbi.nih.gov/hbp/ [Accessed 24 May 2010]. Read More