NCP Draft Asessment

8/10/2019 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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Cues & Nursing DiagnosisObjectives of

Care


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

-

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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Cues & Nursing DiagnosisObjectives of

Care


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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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


7/12

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


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


8/12

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.


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


treatment, self care

and home needs


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.


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.

NCP Draft Asessment

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