Nursing Care Plan Essay

1254 Words 6 Pages
Nursing Care Plan
A 65 years old Caucasian female widow for 20 years who lives alone; however, she has two grown up daughters who live in the nearby community; two older sisters are alive and well, one with osteoporosis is 75 years old and was diagnosed at age of 55. The other one with breast cancer, she is 72 years old and was diagnosed at age of 60. Over the past ten years the patient’s perception of self–efficacy has been declining. Patient has become increasingly short of breath for the past two weeks following any kind of activity because the cough; which is mainly dry, rarely productive, and particularly during the night which she needs to sit up in a chair to be able to breathe easier. In addition, her appetite has decreased, but
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Respiratory rate 20 non-labored, producing a white material on the buccal mucosa; which does not wipe off with tongue blade. Other vital signs: temperature: 101.F, pulse: 100 BMP (regular), blood Pressure: 130/72mmHg, pulse oximeter: SAO 98% RA. Auscultation reveals decreased breath sounds, dull to percussion right lower lobe. End expiratory wheeze in right lower lobe, as well as an increased anterior-posterior diameter to chest wall, no rales or rhonchi. Chest X-ray results shows hyperinflation of both lungs with an increased AP diameter. There is evidence of emphysema. Initial laboratory work reveals increased white blood cells of 15,000.
Admitting orders include arterial blood gas, sputum specimen for culture, pulmonary function tests, complete blood count –CBC and comprehensive metabolic panel- CMP; methylprednisolone, intravenous antibiotic medications, but avoiding sulfa drugs which include: Co-Trimozole, Sulfadiazine, Sulfamethoxazole, Trimethoprim-Sulfa-methoxazole ( Bactrim, Bactrin DS, and Septra), and Timethoprim (Trimpex, Proloprim, and Primsol). Patient should be on bed rest with bathroom privileges; oxygen per nasal cannula at 2litters continuously to keep saturation above 92%; and regular
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However, she does have supportive resource group. She goes to church and has contact there, which helps low her level of day-to-day stress. In addition, patient is financially stable, but she has little knowledge of community resources that are at her disposal. For example, patient should be encouraged to join a stop-smoking program. There are even telephone, text message, and Internet programs.
Social services for assistance, especially because her insurance does not cover all her prescriptions medications and she can be benefit by government prescriptions program. Patient needs a lifestyle changes, and will benefit by a nutritionist to coach with a good nutrition guidance to make her body stronger. Eating variety of foods every day can help her to prevent shortness of breath by eating six small meals, select foods that need little preparation, eat slowly, and avoid gas-forming foods. In addition, exercise is important to build up the body as well as enhance muscles by make them more efficient, gain strength, flexibility, and endurance which decrease shortness of breath when perform activities of daily living (Fredericks & Guruge,

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