Chamberlain College of Nursing NR305 Health Assessment
CourseProject Milestone #2: Nursing Diagnosis and Plan of Care Form
Your
YourInstructor’s
Directions:Refer to the Milestone 2: Guidelines found in Doc Sharing to completethe information below. This assignment is worth 250 points, with 10points awarded for clarity of writing, which means the use of propergrammar, spelling, and medical language.
Typeyour answers on this form. Click “Save as” and save the file withthe assignment name and your last name, e.g.,“NR305_Milestone2_Form_Smith”. When you are finished, submit theform to the Milestone 2 Dropbox by the deadline indicated in yourguidelines. Post questions in the Q & A Forum or contact yourinstructor if you have questions about this assignment.
1:Analyze Assessment Data:
Basedon the health history information, identify the following:
A.Areas for focused assessment (30 points)
Providea briefoverview of those areas of strength and weakness noted from Milestone1: Health History.
The client’s areas of weakness were identified to be leading tohealth concerns. They include smoking, where the client uses 3-4sticks per day. He is also an alcohol user taking whiskey frequently.He has a problem with his breathing. Peripheral capillary dilatationis also another concern. He is genetically predisposed totuberculosis because his grandparents both died due to pulmonarytuberculosis. The main areas for the focused assessment are therespiratory, the gastrointestinal, and cardiovascular systems.
His areas of strength include a high regard for hospital care andregular check-up, availability of appropriate support systems,strong religious background, high regard of himself, academicachievements, ability to raise enough finances, and being blood groupAB, rhesus positive.
B.Client’s strengths (30 points)
Expandon areas identified as strengths related to the person`s overallhealth. Support your conclusions with data from the textbook.
Highregard for hospital care is vital because the client always seeks thestandard and recommended healthcare. Hospitals have qualified healthworkers who collaborate with each other to ensure the health issuesof the client are managed. A regular medical check-up is a primaryprevention measure curbing unnecessary health problems. Supportiveindividuals such as friends and family help the client in maintaininghealth, and adhering to the doctor’s instructions. This client willneed support for him to follow the TB treatment regimen strictly.
Astrong religious background promotes health through regulating theclient’s unacceptable behaviors such as alcoholism. Utilizing thereligious leaders and mates in the provision of psychological supportand motivation ensures good health.
Theclient has a high regard for himself and has future plans offurthering his education. This is vital in keeping good health sothat he can achieve it. The most probable reason for smoking andalcohol use for this client is an addiction therefore, when guidedprofessionally, and reminded of his goals, he can quit smokingbecause of the willingness (Donatelle,2012).
Hegraduated from the University of Philadelphia with a degree inmedical technology. It shows that he has knowledge of healthimportance. He can follow instructions to the latter, and achievegood health status. He is blood group AB, Rhesus positive, meaningthat he is a universal recipient. In any emergency scenario, he canbe transfused with anybody’s blood and in the end solving thehealth condition.
C.Areas of concern (30 points)
Expandon areas previously identified as abnormal and those that place theperson at a health risk. Support your observations with data from thetextbook.
Smokingis a predisposing factor for respiratory diseases such as ChronicObstructive Pulmonary Disease, bronchitis, and others. It also causescancer, especially that of the lungs. It triples the death risk fromheart-related conditions than a normal person. It is the cause ofdilatation of peripheral capillaries in this client. The patient alsohas dental plaque and gingivitis due to smoking (Hayashi,2012).
Chronicand excessive use of alcohol can cause liver cirrhosis and predisposeone to mental conditions such as substance induced psychosis. It cancause cardiac damages leading to conditions such as stroke,arrhythmias, cardiomyopathy and hypertension. Oral, breast, liver andesophageal cancer risks are increased. Alcoholism lowers the bodyimmunity paving the way for infections (Sethi,2015).
Thebreathing problem is due to pleural effusion. It affects oxygendelivery to the body tissues. In the long run, there may be ischemiaof some organs.
Thepatient had been diagnosed with attention deficit disorder. It isvital to establish the main cause because of the history of smokingand alcohol use.
Thegenetic predisposition to tuberculosis is probable because it is acondition known to have caused the deaths of his grandparents.Alcoholism may be as a result of influence from his father who diedin an accident. The client was not immunized with BCG despite havinghigh chances of having TB due to heredity.
D.Health teaching topics (30 points)
Identifyhealth education needs. Support your statements with facts from theHealth History and information from your textbook.
Thehealth education topic prioritized for this client is firstlysmoking, its effects, and means of quitting. This client hasextra-pulmonary tuberculosis and still smokes, making it difficult tomanage his condition because smoking aggravates it (Leone,2012).
Adherenceto the TB treatment. Because of the side effects of the drugs and theprolonged period of use, many clients default, making it difficult toeliminate the mycobacterium bacteria.
Effectsof alcoholism. Alcohol aggravates poor health. Encouraging theclient slowly helps him to lower the amounts of whiskey that hetakes. It is because the alcohol volume in whiskey is high, and maycause lethal effects when not regulated (Sethi,2015).
Nutrition. Maintaining a balanced nutrition is essential in promotingfull recovery from TB. It is because nutrients boost the bodyimmunity, increasing its capacity to combat pathogens. This clienthas financial stability, and can adhere to the directives from thenutritionist.
Education on the need for body fitness is important in maintaining anormal body weight. It also reduces the risk of developing diseasessuch as hypertension, stroke, kidney disease and others.
Oralhygiene. The client has gingivitis and dental plaque due to smokingand poor dental hygiene. Upholding oral hygiene principles such asbrushing the teeth after every meal eliminates the risk for oraldiseases.
2:Nursing Plan of Care
Next,plan your care based on your analysis of your assessment data:
A.Diagnosis (30 points)
Writeonenursing diagnosis that reflects a priority need for this person.Remember a health promotion diagnosis is a possibility.
Ineffectivebreathing pattern related to decreased volume capacity of the lungsas evidenced by distressed breathing.
B.Plan (30 points)
Writeonegoal and onemeasurable expected outcome related to your nursing diagnosis. Explain why this goal and outcome is a priority. Include culturalconsiderations for this client.
Thepatient will demonstrate the appropriate behaviors of coping andmethods towards improving the pattern of breathing.
After7 hours, the patient will demonstrate a normal breathing pattern ofbetween 16 and 20 breaths per minute.
Thegoal and expected outcome are prioritized in this case because thepatient is not breathing normally due to pleural effusion. Oxygendelivery for cellular uptake is compromised and could pose a greatrisk to the tissues. The client is of Caucasian origin, and they areknown to be susceptible to Tuberculosis.
C.Intervention (30 points)
Writeas many nursing orders, or nursing interventions, that you need inorder to achieve the outcome. Provide the rationale for eachintervention listed.
Administrationof supplemental oxygen 2 Liters per minute. Rationale: To maximizeoxygen availability of oxygen for cellular uptake.
Explanationof smoking and alcohol effects. Rationale:Promotes good understanding and eventual weaning of smoking andalcohol use by the patient.
Assistand prepare the patient for paracentesis through:
Explaining the expectations such as a sensation that is stinging from the local anesthetic site, and a pressure feeling when the needle is introduced. Rationale: Relieves anxiety.
Instruct him to report immediately when he feels uncomfortable or experiences breathing difficulties. Rationale: Postponing the procedure may be required if DOB occurs.
Monitoring vital signs during the thoracentesis procedure. Rationale: Quick removal of fluid may cause pain, hypotension, bradycardia, cardiac arrest and even pulmonary edema.
Ensuring tube patency during the procedure. Rationale: Bubbling that is continuous may indicate air leakage.
Reassurance of the patient during through the process and reminding him to breathe normally and with ease. Rationale: It relieves anxiety (Sethi, 2015).
Assistthe client in utilizing the relaxation techniques. Rationale:Facilitates resting periods andlimits fatigue.
Demonstrateto the patient on performing deep breathing technique. Rationale: Itpromotes lung expansion.
Elevationof the patient’s head at 45 degrees. Rationale: Promotes lungexpansion.
Assessmentof respiratory rate, breath sounds and rhythm. Rationale: To identifyrespiratory abnormalities that may result in hypoxia and ischemia(Sethi,2015).
Provisionof a relaxing environment. Rationale: Promotes adequate periods ofresting and relieving fatigue.
Encourageadherence to the regimen. Rationale: Promotes healing and eliminatesreoccurrence(Hillegrass, 2014).
D.Evaluation (30 points)
Youwill not carry out your care plan so you cannot evaluate theeffectiveness of your nursing interventions. Instead, comment on whatyou would look for in order to evaluate your effectiveness.
Iwill consider:
The vital signs, mainly respiration and its pattern.
The patient’s understanding of the instructions explained to him.
The drug chart for adherence.
The patient’s general health is focusing on oral hygiene.
Information from the support systems to see whether the client is cooperative (Sethi, 2015).
References
Donatelle,R. J. (2012). Accessto health.San Francisco, Calif: Benjamin Cummings.
Hayashi,I. (2012). Smoking:Health effects, psychological aspects, and cessation.New York:
NovaBiomedical Books.
Hillegrass,E. A. (2014). PTclinical notes: A rehabilitation pocket guide.Philadelphia: F.A.
DavisCompany.
Leone,A. (2012). Passivesmoking and cardiovascular pathology.Hauppauge, N.Y: Nova
Science.
Sethi,D. (2015). Medical-surgicalnursing i and ii.S.l.: Jaypee Brothers Medical P.
Milestone #2: Nursing Diagnosis and Plan of Care Form11/5/15 as | 0 |