Patient assessment should be completed and attached
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Course
N3632
Institution
N3632
Patient initials: _VB____ Room #: _517___ Gender: __M___ Age: ___67_ Admit date to hospital: __2/1/2017____
Medical diagnosis: _____Chronic Obstructive Pulmonary Disease (COPD)_________ Date of surgery: (if applicable) ____N/A___________
Basic Health History: (History of current complaint includi...
patient assessment should be completed and attached
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**Patient assessment should be completed and attached (assessment form 10 points, lab/diagnostic data 5 points)
Clinical Nursing Foundations N3632 Student name __Hannah Peoples_________________
CLINICAL NURSING FOUNDATIONS CARE PLAN Care Plan Date you had patient _________2/7/2018______
Clinical Instructor_______Mrs. DL_____________
Patient initials: _VB____ Room #: _517___ Gender: __M___ Age: ___67_ Admit date to hospital: __2/1/2017____
Medical diagnosis: _____Chronic Obstructive Pulmonary Disease (COPD)_________ Date of surgery: (if applicable) ____N/A___________
Basic Health History: (History of current complaint including timeline of when it started, characteristics, and what finally made client come to hospital; allergies; chronic illnesses;
past hospitalizations & dates; surgical history & dates; family history pertinent to current illness; substance use, support system; source of your information in this section) (5
points)
Mr. Vincent Brody is a 67 year old male patient who is alert and responsive. He is being admitted to the medical unit with a diagnosis of COPD exacerbation. The patient
is complaining of increasing fatigue with activity and stated “he does not sleep well at night”. He also has increased sputum production and cough. Patient has a 50 year
history of smoking 2 packs of cigarettes a day. He has continued to smoke despite his health care provider’s recommendations to quit. During the last year he has been
hospitalized for two exacerbations regarding his COPD.
Allergies: NKDA, no food or environmental allergies
Chronic Illnesses: COPD
Past Hospitalizations and dates: An appendectomy in 2000 and a cardiac catheterization in 1990
Surgical History: An appendectomy in 2000 and a cardiac catheterization in 1990
Family History: His father died of colon cancer at the age of 57, mother died of heart disease at the age of 88, maternal grandfather had COPD
Substance Use: Not documented
Support System: wife and two grown children
Source of information: PT and EHR
Pathophysiology of admitting medical diagnosis and how the pathophysiology relates to or shows up in your patient. (Source is pathophysiology book or similar resource. Must
be substantive.) (10 points)
Admitting Diagnoses: COPD exacerbation
Patho and s/s: COPD is “Widespread inflammation occurs, leading to airway narrowing and mucus within the airways—all producing resistance in the small airways
and, consequently, a severe ventilation-perfusion imbalance (lippincott advisor)
How does the disease and disease process present in your patient: Patient has complained of increasing fatigue with activity and inability to sleep well at night. He has also
had increased sputum production and cough. Patient has a 50-year history of smoking 2 pack/day. He has continued to smoke despite health care provider’s
recommendation. During the last year, he has had two exacerbations.
Look at your patient’s assessment form. Look for patterns and groupings of assessment data. Think of nursing diagnoses that might apply and read their defining characteristics.
List all the Nanda nursing diagnoses you think apply to your patient according to your assessment data and put them in order according to priority. #1 would be the nursing
diagnosis you think is most important for your patient. Think Maslow and ABCs. Please put “Risk for” diagnoses here but do not prioritize them (see instructions).You must add
spaces for more nursing diagnoses. Hit tab key when you come to last line. (20 points)
Priority # Nursing diagnosis and etiology (related to) Assessment Data (aka defining characteristics and AEB)
(Safety) -Patient was diagnosed with COPD
Risk for ineffective peripheral tissue perfusion RT impaired breathing -Pulse oximetry at 86%
-Patient was a smoker for 50 years
N3632 Foundations (revised 08/10/2015) 1
, 1 (Diagnosis 1) -Patient had respiratory rate of 23
Impaired gas exchange RT pulmonary obstruction AEB PT statement of smoking -Patient had increased sputum production and cough
2 packs of cigarettes/day -Patient was wheezing
2 (Diagnosis 2) -Tachypnea
-Bilateral wheezing throughout lung field of anterior chest
Ineffective breathing pattern RT excess secretions AEB decreased oxygen
saturation
(Diagnosis 3, etc.)
After you have finished with the prioritization…take your top two nursing diagnoses and one of the safety diagnoses and work them into a care plan. (This section is done three
times. 10 points for each of the three sections- total 30 points)
Priority #1 Diagnostic statement: __Impaired gas exchange RT pulmonary obstruction AEB PT smoking 2 packs of cigarettes/day_____
Body of Care Plan:
1 patient goal 4 interventions that advance your 1 rationale for each Implementations (Tell exactly Result of your Evaluation of
(SMART) goal intervention (give source) what you did and at what time.) implementations the patient goal
1. Patient’s 1. 1. When respiratory rate 1. 1. Date:
respirations will Monitor respiratory rate, depth, and exceeds 30 breaths/minute RR was auscultated and inspected PT has coarse crackles, Time:1400
be 12-20 by ease of respiration q4 PRN along with other at 1000, then reassessed at 1400 coughing, and RR 24. Goal Met AEB
1400 physiological measures, a Reassessment showed RR 20
significant cardiovascular or RR 20 after intervention Continue to
respiratory alteration exists monitor
( Ackley pg 404)
2.Assess patient for pain by asking 2. Self-report is considered 2. 2.
him to rate his pain on a 0-10 scale the single most reliable PT was questioned to rate pain PT rates pain as 2/10
indicator of pain presence level and visually inspected for
and intensity and single- signs of discomfort at 1130.
dimensional pain ratings are
valid and reliable measures
of pain intensity level
(Ackley pg. 640)
3. 3. Quitting smoking will 3. 3.
Educate on smoking cessation decrease the number of Discussed with patient the long PT states “I will try
exacerbations experienced, term effects of smoking and gave harder to quit”
as well as associated brochures and other resources at
symptoms. Relinquishing 1130.
N3632 Foundations (revised 08/10/2015) 2
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