NCP Draft Asessment
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Transcript of NCP Draft Asessment
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Subjective & Objective
Cues & Nursing
Diagnosis
Objectives of
Care
Intervention & Rationale Implementation & Monitoring
Evaluation
Criteria
July 2009
6. Monitor level of consciousness, mental status. Investigate
changes.
- Restlessness & anxiety are common manifestation of hypoxia.
7. Evaluate level of activity tolerance. Provide calm, quite
environment. Limit patients activity or encourage bed /chair rest
during acute phase. Have patient resume activity gradually and
increase as individually tolerated.
- During severe/acute/refractory respiratory distress the patient
maybe totally unable to perform basic self-care activities because
of hypoxemia and dyspnea. Rest interspersed with care activities
remains an important part of treatment regimen. An exercise
program is aimed at increasing endurance & strength without
causing severe dyspnea, and can enhance sense of well-being.
8. Evaluate sleep patterns, note reports of difficulties & whether
patient feels well rested. Provide quite environment, group
care/monitoring activities to allow periods of uninterrupted sleep;
limit stimulants e.g., caffeine, encourage position of comfort.
- Multiple external stimuli & presence of dyspnea may prevent
relaxation & inhibit sleep.
9. Administer supplemental O2 judiciously as indicated by ABGresult/O2 sat & patient tolerance.
- may correct/prevent worsening of hypoxia.
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He is able to rest a
manage to prevent
control dypneic
episode.
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Subjective & Objective
Cues & Nursing DiagnosisObjectives of
Care
Intervention & Rationale Implementation & Monitoring
Evaluation
Criteria
July 2009
Subjective:
Malisud yo risulya sita
tose dol ta kaba y palta
myo ayre
Objective:
- adventious breath
sounds, wheezes.
- Persistent Cough with
mucus production
- RR- 35 Pulse-80
-
Difficulty vocalizing
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Restlessness
- Cyanosis at nail beds.
- Chest tightness
Nursing Dx:
Ineffective Airway
Clearance related to
increased mucus
production, ineffective
cough & bronchopulmonary infection
After 10 days of
nursing
intervention the
client will be able
to:
Maintain
patent airway
with breath
sounds
clear/clearing
Demonstrate
behaviors to
improve
airway
clearance,
e.g., cough-
effectively &
expectorate
secretions.
1. Auscultate breath sounds. Note adventitious breath sounds, e.g.,
wheezes, crackles, rhonchi.
-some degree of bronchospam is present with obstructions in airway &
may/may not be manifested in adventitious breath sounds, e.g.
scattered, moist crackles ( bronchitis)
2. Assess/monitor respiratory rate. Note inspiratory/expiratory ratio.
Also monitor pulse oximetry.
- Tachypnea is usually present in some degree & may be pronounced
on admission or during stress/concurrent acute infectious process.
Respirations maybe shallow & rapid with prolonged expiration for
comparison to inspiration.
3. Note presence/ degree of dyspnea, e.g., reports of air hunger,
restlessness, anxiety, respiratory distress, and use of accessory
muscles.
- Respiratory dysfunction is variable dependent on stage of chronic
process in addition to acute process that precipitated hospitalization,
e.g., infection, allergic reaction.
4. Assist the patient to assume position of comfort, e.g., elevates head
of bed, sitting on edge of bed.
-Elevation of the head of the bed facilitates respiratory function by useof gravity; how ever, the patient in severe distress will seek the position
that most eases breathing. Supporting arms/legs with table, pillows, &
so on helps reduce muscle fatigue & can aid chest expansion.
5. Keep environmental pollution to a minimum, e.g., dust, smoke, &
feather pillows accdg. To individual situation.
-Precipitators of allergic type of respiratory reactions that can trigger
onset of acute episode.
6. Encourage/ assist with abdominal or pursed-lip breathing exercises.
- Provides the patient with some means to cope with and control
dyspnea & reduce air-trapping.
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The client
verbalizes
understanding
causes &
therapeutic
management
regimen.
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Subjective & Objective
Cues & Nursing DiagnosisObjectives of
Care
Intervention & Rationale Implementation & Monitoring
Evaluation
Criteria
July 2009
7. observe characteristic of cough, e.g. persistent, hacking. Moist.
Assist with measures to improve effectiveness of cough effort.
- Cough can be persistent but ineffective, especially if the patient is
elderly, acutely ill, or debilitated. Coughing is most effective in an
upright or in a head-down position after chest percussion.
8. Increase fluid intake to 3,000 ml/d with in cardiac tolerance.
Provide warm & tepid liquids. Recommend intake of fluids between,
instead of during, meals.
- Hydration helps decrease the viscosity of secretions, facilitating
expectoration. Using warm liquids may decrease bronchospasm. Fluids
during meals can increase gastric distention & pressure on the
diaphragm.
9. Administer medication as indicated.
- Bronchodilators, relax smooth muscles & reduce local congestion
reducing airway spasm, wheezing, & mucous production.
-antimicrobials; various antimicrobials maybe indicated for control of
respiratory infection/pneumonia.
-analgesics, cough suppressants/institutive; persistent, exhausting
cough may need to be suppressed to conserve energy & permit the
patient to rest.10. Provide supplemental humidification; nebulizer & breathing
exercise.
- Humidity helps reduce viscosity of secretions facilitating
expectoration & may reduce, prevent formation of thick mucous plug in
bronchioles.
-breathing exercises help enhance diffusion.
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The client is a
to expectorate
secretion read
& improves
oxygen excha
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Subjective & Objective
Cues & Nursing DiagnosisObjectives of Care
Intervention & Rationale Implementation & Monitoring Evaluation
CriteriaJuly 2009
Subjective:
Kere yo puma poko, otro
myo risuwelyo.
Objective:
Shortness of breath
statement of
misconception
difficulty stoping
smoking
request to smoke
RR= 35 bpm
Pulse-80bpm
O2 sat85%
BP140/100mmHg
Nursing Dx:
Knowledge deficit
regarding condition,
treatment, self care and
home needs
After 10 days of
nursing intervention
the client will be
able to:
Verbalize
understanding
of condition/
disease process
& treatment.
Identify
relationship of
current
signs/symptoms
to the disease
process &
correlate these
with causative
factors.
Initiate
necessarylifestyle
changes &
participate in
treatment
regimen.
1. Explain / reinforce explanations of individual disease process.
Encourage patient/SO to ask questions.
- Decreases anxiety and can lead to improved participation in
treatment plan.
2. instruct/ reinforce rationale for breathing exercises, coughing
effectively, & general conditioning exercises,
- Pursed-lip and abdominal/diaphragmatic breathing exercise
strengthen muscles of respiration, help minimize collapse of small
airways, and provide individual with means to control dyspnea.
General conditioning exercises increase activity tolerance, muscle
strength, and sense of well-being.
3. Discuss respiratory medications, side effects, adverse reactions.
- It is important that the patient understand the difference between
nuisance side effects (medication continued), & untoward or adverse
side effects (medication possibly discontinued/changed).
4. Demonstrate technique using inhaler, such as how to hold it,
taking 2-5 minutes between puff, cleaning the inhaler.
- Proper administration of drug enhances delivery and effectiveness.
5. Recommend avoidance of sedative anti anxiety agents unless
specifically prescribed/approved by physician treating respiratory
condition.-although the patient may be nervous & feel the need for sedatives,
these can depress respiratory drive & protective cough mechanism.
6. Stress importance of oral care/dental hygiene.
- decreases bacterial growth in the mouth, which can lead to
pulmonary infections.
7. Discuss individual factors that may aggravate condition, e.g.,
excessively dry air, wind, environmental temperature extremes,
pollen, tobacco smoke, aerosol sprays, and air pollution. Encourage
patient/ So to explore home.
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The client
verbalizes
understanding
of his conditio
and the
causative
factors but
finds hard tim
to quit
smoking.
Subjective & Objective Intervention & Rationale Implementation & Monitoring Evaluation
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Cues & Nursing Diagnosis Objectives of Care July 2009 Criteria
-These environmental factors can induce/aggravate bronchial
irritation leading to increase secretion production and airway
blockage.
8. Review the harmful effects of smoking and advise cessation of
smoking by patient and/or SO.
- Cessation of smoking may slow/halt progression of COPD. Even
when patient wants to stop smoking, support groups and medical
monitoring may be needed.
9. Provide information about activity limitations and alternating
activities with rest periods to prevent fatigue; ways to conserve
energy during activities (e.g., pulling instead of pushing, sitting
instead of standing while performing task); use pursed-lip
breathing, side lying position.
- having this knowledge can enable patient to make informed
choices/decisions to reduce dyspnea, maximize activity level,
perform most desired activities, and prevent complications.
10. Discuss importance of medical follow -up care, periodic chest
x-rays, sputum cultures.
- monitoring disease process allows for alterations in therapeutic
regimen to meet changing needs & may help prevent complications.
11. Review oxygen requirements/ dosage for patient who is
discharged on supplemental oxygen. Discuss safe use of oxygen.
- reduce risk of misuse (too little/ too much) and resultant
complications. Promotes environmental/ physical safety.
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Initiated
willingness
lifestyle
changes a
participates
treatment
regimen.
Subject: Therapeutic Treatment Regimen for Respiratory Disorder COPD & CAP
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Time Allotment: 30 minutes
Objective: At the end of the 30 minutes of health teaching, the client will be able to verbalize understanding of the therapeutic treatment regimen and lifestyle
modification appropriate for client with COPD & CAP.
Table 4. Health Teaching Plan
Assessment Teaching Objective Content Teaching Strategy
/Teaching Tool
Evaluation
Subjective:
Kere yo puma
poko, otro myo
risuwelyo.
Objective:
Shortness of
breath
statement of
misconcep
tion
difficulty stoping
smoking
request to smoke
RR= 35 bpm
Pulse-80bpm
O2 sat85%
BP140/100mmHg
Nursing Dx:
Knowledge deficit
regarding condition,
treatment, self care
and home needs
At the end of 30 minutes
health teaching, the client
will be able to:
1. Discuss the disease
process
2. Discuss the therapeutic
management & treatment
regimen for COPD & CAP
3. Initiate lifestyle changes
that will help improve his
condition
Overview of COPD & CAP the cause & effects on health.
- COPD Chronic Obstructive Pulmonary Disease- broad classification of disorder including
chronic bronchitis, bronchiectasis, emphysema & asthma.. Associated with dyspnea on
exertion & reduced airflow.. Risk factors:
Cigarette smoking -Air pollution
Occupational exposure ( coal, cotton, grain)
-CAP (community acquired pneumonia) - inflammatory process of the lung parenchyma
commonly cause by infectious agent.
Therapeutic Management & Lifestyle changes
-Instruct breathing exercises (pursed-lip breathing), coughing effectively, expectorate
secretion & avoiding strenuous activities limit activities to with in tolerance to avoid
dyspnea.
- Proper use of nebulizer &inhaler puff & safety use of oxygen.
-Position to comfort side lying, head of bed elevated, sitting at end of the bed or chair.
- Keep environmental pollution to a minimum, e.g., dust, smoke, & feather pillows
- Importance of adequate nutrition & balance diet following diabetic diet, increase fluid
intake and enough rest & sleep.- Explain health hazard of smoking & importance of smoking cessation.
- Importance of compliance to medication & follow up check up.
Medications: Glibenclamide 3x a day- oral anti diabetic,
Insulin Novomix 5 units (am & pm)
Co amoclav 625 mg TID- Penicillin,
Seretide 250 mg 2 puffs inhaler ( am & pm)- anti asthmatic & COPD preparation
Combivent inhaler 2 puffs ( am & pm) anti ashthmatic & COPD preparation
Lacipil 2mg( once a day)- calcium antagonist, treatment for hypertention
One on one
discussion
Showing
illustration
Asking question: What do
you think is the reason you
experiencing difficulty of
breathing?
Demonstration:
Implementation of
therapeutic management.
Client performed purse-lip
breathing and assisted by S
to position to comfort.
Observation: The client
religiously complies with
medications.
Implementation Phase
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The 10 days monitoring and recording of nursing care plan implementation of Mr. Good from July 21 to July 30,
2009.
Table 5. Monitoring Chart
Nursing Diagnosis July 21, 2009 July 22, 2009 July 23, 2009 July 24, 2009 July 25, 2009
1. Impaired Gas
Exchange related to
ventilation perfusion
inequality.
Monitor vital signs, notetachycardia, O2 sat.
Assisted/teach client how to
position in comfort
Encouraged pursed-lipbreathing & expectoratesputum.
Monitored cyanosis in nailbeds.
Monitored level of mentalstatus. Observechanges. Rendered
oxygen as needed.
Client perform deep breathingexercise & rest
Limit client activity
Encouraged bed/chair rest.
July 26, 2009 July 27, 2009 July 28, 2009 July 29, 2009 July 30, 2009 Client participated in position
to comfort, side lying , turn tosides & head of bed elevated
Adequate fluid intakeencouraged.
Imparted knowledge aboutpresent condition.
Provided calm & quiteenvironment & minimizedust etc. Kept rested.
Client verbalizedunderstanding of health careneeds
Encouraged client to continuewith therapeuticmanagement.
Demonstrate improvingventilation & oxygenation bylessening symptoms ofrespiratory distress.
2.Ineffective Airway
Clearance related to
increased mucus
production,
ineffective cough &
broncho pulmonary
infection
July 21, 2009 July 22, 2009 July 23, 2009 July 24, 2009 July 25, 2009
Auscultated breath sounds,wheezes.
Monitored V/S, dyspnea
Encouraged pursed-lipbreathing
Head of bed elevated Positioned to comfort.
Encourage coughingexercise &expectoratesputum.
Nebulized with assistant.Deep breathingexercises
Praise for following regimen
Limit activity with intolerance. Stressimportance of rest.
July 26, 2009 July 27, 2009 July 28, 2009 July 29, 2009 July 30, 2009
Advised cessation ofsmoking.
Increase fluid with in cardiactolerance & complywith medications
Nebulized with deepbreathing.
Client comprehends self-careneeds.
Client able to expectoratesecretion & improvedoxygen exchange.
Praised client.
3. Knowledge deficit
regarding condition,
treatment, self care
and home needs
July 21, 2009 July 22, 2009 July 23, 2009 July 24, 2009 July 25, 2009
Allow client to expressconcern.
Client stated wanted to go outof room & have a stickof cigarette.
Assess clients level ofunderstanding.
Explain client the diseaseprocess & health hazardof smoking.
Recommend avoidanceuse of sedative &anxiety agents.
Discuss respiratorymedication side effects &adverse reaction(medicationcontinued/discontinued)
Demonstrate technique inbreathing exercise & usinginhaler.
July 26, 2009 July 27, 2009 July 28, 2009 July 29, 2009 July 30, 2009
Discuss factors that canaggravate condition.
Reinforce rationale for breathing
exercises, coughing effectively &
limit activity with in tolerance.
Discuss safe use ofoxygen.
Client realized importance ofself care & treatment.
Client agreed with self care &cessation of smoking.
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Evaluation Phase
Below is the final assessment result of Mr. Good utilizing the same Assessment Tool for
the final evaluation of the level of self-care performance.
Table 6. Final Assessment of Mr. Good
Assessment Parameters No.of
Items
PerfectScore
ClientsScore
MeanScore
Description
I. Universal self-carerequisites
19 76 43 2.3 Average
II. Developmentalself-care requisites
5 20 10 2 Below Average
III. Health DeviationSelf-care requisites
6 24 20 3.3 High
Total 30 120 73 2.5 Average
The table shows that Universal self-care requisites has a mean score of 2.3 which is
average. Followed by developmental self-care requisites with a mean score of 2 described as
below average self-care performance. And lastly, Health deviation self care requisites is with a
mean score of 3.3 which is described as high in self-care performance.
LOW BELOW AVERAGE AVERAGE HIGH
Figure 5. Final Assessment of Mr. Good on the Level of Self-care Performance
Interpretation
The final assessment of Mr. Good has a total score of 73. The mean score were added and
divided by the total number of categories is equal to 2.5 as an overall mean score described as an
average level of self-care performance as demonstrated on the scale.
Table 7. Comparative result of initial and final assessment of Mr. Good level of self- care
performance
43210
2. 5
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Assessment
Parameters
No.
ofItems
Perfect
ScoreClientsScore
Mean
Score
Description ClientsScore
Mean
Score
Description
I. Universal self-carerequisites
19 76 25 1.3 BelowAverage
43 2.3 Average
II. Developmental
self-care requisites
5 20 7 1.4 Below
Average
10 2 Below
AverageIII. Health DeviationSelf-care requisites
6 24 9 1.5 BelowAverage
20 3.3High
Total 30 120 41 1.4 BelowAverage
73 2.5 Average
1.4
LOW BELOW AVERAGE AVERAGE HIGH
Figure 6. Comparative Result of the Initial & Final Assessment of Mr. Good level of self-careperformance
43210 2.5
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FINDINGS
Initial and final assessment was conducted to a client with COPD & CAP through
utilization of questionnaire checklist assessment tool of Orems self care deficit theory. The
client was assessed within three self-care assessment parameters specifically universal self-carerequisites which deals with life process functioning, developmental self-care requisites which
deals with condition or associated with events and health deviation self-care requisites which
includes seeking & securing appropriate medical assistance. The results of the assessment were
computed statistically & mean score was analyzed and interpreted well.
Theinitial assessmentof the client showed a below average self-care performance
with a total mean score of 1.4. Out of 120 total perfect score of all items, the client gathered only
41 total clients score. This described as below average self-care performance. Through the
result of the initial assessment, three problems were prioritized in the nursing care plan. These
problems identified where Impaired Gas Exchange related to ventilation perfusion inequality,
Ineffective Airway Clearance related to increased mucus production, ineffective cough &
broncho pulmonary infection and Knowledge deficit regarding condition, treatment, self care and
home needs. The nursing care plan was implemented from July 21 to July 30.
Implementation of nursing care plan caused improvement in clients self care
performance as shown in the final assessment conducted after nursing interventions &
implementation. Using the same assessment tool as of initial assessment, clients self-care
performance improved from initial assessment 1.4 total mean score ( below average) to 2.5 total
mean score ( average) final assessment . The client made a difference of 1.1 in self-care
performance.
CONCLUSION
The findings obtained indicate that utilization of Orems Theory is beneficial for
client with specific disorder particularly client who has a problem with self-care, it also benefited
the significant others of client who assisted in the care and nurses as well who initiated and
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implemented effective nursing intervention in the care of client. The aim of attaining increase
level of self-care performance for the client with COPD & CAP was achieve by utilizing Orems
Theory as s guide in nursing process. More over, based on the findings there is significant
positive change in clients self-care level of performance when Orems Theory was utilized in
the nursing process.
RECOMMENDATION
Based on the findings and conclusion, the nurse highly recommends the
application of Orems self care deficit theory in the care of clients or patients with specific
disorder specifically clients with poor self-care performance. By utilizing Orems self care
deficit theory in nursing process, the more quality care can be rendered to a client that
contributes to his/her health improvement. And lastly, Orems theory could also leads to a better
nursing care outcome when implemented well.