Patient Education (4pts) Referrals (4pts)
Teach importance of smoking cessation and how it is imperative of the treatment plan to stop worsening of the disease. Teach how to use inhalers and inhaled corticosteroids as ordered. Teach how to do deep breathing and coughing technique. Teach patient to identify and avoid their triggers, things they know will set them off such as allergies or smoking. Teach how to take antibiotics, take the full course. Social work-assess home support systems, assess need for assistive devices, assess further needs Home health-assess if needed to assist with activities of daily living, organizing medication regimen or light housekeeping Smoking cessation support group, referral to primary care provider for medications to support cessation Palliative care to help this patient live the remainder of life comfortably and doing the things that matter to him References Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care . Maryland Heights, MO: Elsevier. Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (n.d.). Medical-surgical nursing: Assessment and management of clinical problems. Lilley, L., Rainforth Collins, S., Snyder, J. (2014). Pharmacology and the nursing process (7 th Ed.) St. Louis, MO: Elsevier Mosby.
Actual Nursing Diagnosis (Priority Physical) (5pts) Plan/Outcome Criteria (1pt) Interventions (4pts) Rationale for Interventions (Referenced) Evaluation #1 Ineffective airway related to damage done to respiratory system organs as evidenced by abnormal breath sounds, dyspnea, changes in respiratory rate and rhythm. 1. Patient will continue to maintain a patent airway through time of discharge. 1. Assess respiratory effort and rate, count respirations per minute and oxygen saturation levels 2. Position the patient to increase respiratory function, head of bed elevated 30-45 degrees. 3. Administer bronchodilators as ordered and needed. 4. Administer oxygen as ordered, titrate as ordered. 1. Normal respiratory rate is 12-16 for a dyspneic adult (Ackley & Ladwig, p.129). 2. Upright position gives maximum lung expansion (Ackley & Ladwig, p.129). 3. These meds will decrease the airway resistance and improve respiratory function (Ackley & Ladwig, p. 129). 4. Giving oxygen has been shown to improve hypoxemia (Ackley & Ladwig, p.129). 1. Patient will continue to maintain a patent airway through time of discharge. Goal unmet, did not see through discharge. #2 Activity intolerance related to imbalance of oxygen supply and demand as evidenced by abnormal responses to activity, EKG 1. Patient will demonstrate increased tolerance to activity by ambulating with nurse by side to restroom before discharge.
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- Fall '16
- Nursing, normal range, Lilley et al., abnormal results