1
LaGuardiaCommunity CollegeCityUniversity of New York / Client’s Initials T.F. Room 223B
Age7y/o Sex Female Religion Catholic
Occupation None / Admitting DiagnosisRespiratory Airway Distress
Secondary Diagnosis .
Surgical Procedure None
Student Name Louise Margaret Tomas
Date:10/28/2008 / Cultural/Ethnic BackgroundAfrican American
Admitting Date: 10/26/2008
Reason for Admission: Respiratory Distress
. / Date .
Health History Hx of Status Asthmaticus Allergic: Peanuts; wheat and chocolate..
.
270 SAMPLE NURSING PROCESS TOOL
Need Data - Label S for Subjective, O for Objective Data AnalysisNursing Diagnosis
R / Rest:Hours of sleep each night
Pt’s grandmother stated that she normally sleeps 6-7 hours everyday. (S)
Difficulty falling asleep; early awakening
Pt’s grandmother states that she does not have any problems falling sleep. Pt’s grandmother states that it’s problematic for her daughter to fall asleep in the hospital. Pt’s grandmother states that doesn’t have problems awakening during the day. (S)
Nap during day
Pt’s grandmother states that her daughter takesa nap during the day. (S)
Assistive Measures: warm milk, medication, etc.
Pt states that she doesn’t take assistive measures to fall asleep. (S)
Manifestations of sleep deprivation
None
Activity
Degree of mobility of all joints
Full ROM in RUE, LUE, RLE and LLE. (O)
Condition of joints
No pain, and no complications when performing ROM. (O)
Strength needed to flex & extend limbs against resistance
Pt presented strength when flexing and extending limbs against resistance (O)
Hand grasp: bilateral
Pt is able to grasp her hands bilaterally (O)
Coordination
Pt is well coordinated in her movements (O)
Posture, gait
Pt maintains a good posture and gait. (O)
Assistance needed to transfer, stand, walk
Pt does not need of assistance to transfer, stand or walk. (O)
Use of assistive devices (cane, crutches, walker, wheelchair)
Pt does not require the use of assistive devices such as cane, crutches, walker, or wheelchair. (O)
Ability to perform ADL
Pt is able to perform ADL (O)
Restrictions imposed by health problems / therapeutic modalities
No restrictions were imposed by the health care team (O) / Factors Affecting Sleep/Illness
Illness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep than normal, and the normal rhythm of sleep and wakefulness is often disturbed.
(K&E p. 1117)
Factors Affecting Sleep/Environment
Environment can promote or hinder sleep. Any change-for example, noise in the environment-can inhibit sleep. The absence of usual stimuli or the presence of unfamiliar stimuli can prevent people from sleeping. Discomfort from environmental temperature and lack of ventilation can affect sleep. Light levels can be another factor. A person accustomed to darkness while sleeping may find it difficult to sleep in the light.
(K&E p. 1117) / Disturbed Sleep Pattern r/t thinking about home, noise, interruptions for therapeutics, shortness of breath AEB pt hospitalized since 10/26/2008, noise of the hospital’s floor, and pt’shistory of asthma.
Risk for Activity Intolerancer/t imbalance between oxygen supply and demand
Need Data - Label S for Subjective, O for Objective Data Analysis Nursing Diagnosis
E / UrinaryVoiding (Usual, alterations associated with illness andhospitalization)
Pt states that she “uses the bathroom when she needs to go” (S); the grandmother stated the pt. uses the rest room every 3 or 4 hours. (S)
Frequency, urgency, dysuria
Pt’s mother states that her daughter voids every 4 hours, and has no pain when voiding. (S)
Urine: quantity, color, clarity, odor, Sp. G.
Pt’s grandmother states that the color of her urine has a clear yellow color, and no odor. Specific gravity and quantity were not possible to assess due to the fact that pt is not on strict I&O, and there is no urine analysis available. (S+O)
Lab: urinalysis, C/S, BUN, creatinine
Unable to assess. No urine analysis results were available. (O)
Assistive devices (indwelling, external catheter)
No assistive devices were needed. (O)
Structural adaptations: urinary diversions
No structural adaptations were noted. (O)
Retention/bladder distention
No bladder distention was noted. (O)
Bowel
Evacuation patterns (Usual, alterations associated with illness & hospitalization)
Pt’s grandmother states that she hasn’t had any alterations in her bowel movements. (S)
Stool: quality, color, consistency, presence of blood, mucus
Unable to assess. Pt did not have a bowel movement at the time of the assessment. (O)
Assistive measures: laxative, enemas, suppositories
No assistive measures were needed. (O)
Bowel sounds
Normal bowel sounds were heard. (O)
Abdomen: distension, firmness, tenderness
No distension, firmness, or tenderness was noted when assessing the pt. (O)
Structural adaptation: ostomies
Ostomy was not noted when assessing the pt. (O) / Constipation
Constipation is characterized by a decrease in the frequency or passage of stools; the formation of hard, dry stools; or the oozing of liquid stool past a collection of hard, dry stool. Because stooling patterns vary among children, identification of an abnormal pattern is sometimes difficult.
(London et al, p 1603) / Risk for constipation r/t decreased motility of GI tract, and insufficient physical activity.
Need Data - Label S for Subjective, O for Objective Data Analysis Nursing Diagnosis
A / Manifestations of anxiety/stageModerate anxiety was perceived on the pt. Pt wanted to go to the playroom, but because of the nebulizer treatment it was hard to take her there. However, she played with her dolls in her room. (O)
Use of defense mechanisms
The use of reflection was noted on the pt. She canalized her desire to be outside and have her normal life back again onto his father. (O)
Coping mechanisms (appropriate vs. maladaptive)
Appropriate coping mechanisms were used by the pt. She received the support of her family. Pt coped appropriately with her current stay at the hospital. (O)
Self concept/body image
Self concept was not an issue for the pt. She felt the love and support of her parents. (S)
Self esteem
Pt maintains a good self esteem. Pt felt the love and support of her parents. (S)
Attitude
Pt presents a good attitude toward others. (O)
Affect: withdrawn, sad, cheerful, angry, blank expression
Pt presents a cheerful affect. (O)
Ability to communicate (verbal & nonverbal)
Pt is able to communicate verbally and non-verbally. (O)
Barriers to communication: language, faculty, aphasia, tracheotomy/ E.T. tube, perceptual impairments, developmental disorders, etc.
No barriers to communication were present. Pt was able to express herself without any difficulties. (O)
Primary language/ability in English
Pt’s primary language is English. (O)
Family constellation/role within family
Pt’s family is composed by her,her parents and her grandmother.
Living arrangements
Pt and her family live in Queens. (S)
Significant others
Pt does not have a significant other. (S)
Family situation: recent changes or crises
Pt’s hospitalization. (S)
Hobbies
Pt states that she likes playing with her dolls, and putting make up on them. (S)
Level of education
None (S)
Cultural/ethnic influences
Pt is American, African American Descent. (S)
Formal religion
Pt is Catholic. (S)
Family economic situation (socioeconomic status)
Pt’s parents are able to support pt and her family. Both pt’s parents work and contribute to the pt’s household.
Patterns of sexual function (alterations associated
with illness)
Pt is not sexually active. (S)
Menstrual pattern:
Pt does not have her first menstrual period yet. (O)
Reproductive history/disorders: urethralvaginal discharge
Pt does not have any reproductive disorders. (O)
Stage of growth and development: achievement of
Developmental tasks.
Pt denotes self-control without loss of self-esteem, and is able to cooperate and to express oneself. This is part of Erikson’s developmental stage of Industry vs Inferiority
She also tried to develop a sense of self-worth by refining skills.
. / Anxiety
State of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. Anxiety can be experienced at the concious, subconcious, or unconcious level.
(K&E p. 1017)
Self-Esteem
Self-esteem is one's judgement of one's own worth, that is, how that person's standards and performances compare to others and to one's ideal self. If a person's self-esteem does not match with the ideal self, the low self-concept results.
(K&E p. 961)
Illness
Illness and trauma can also affect the self-concept. People respond to stressors such as illness and alterations in function related to aging in a variety of ways: acceptance, denial, withdrawal, and depression are common reactions.
(K&E 962)
Role Performance
Throughout life people undergo numerous role changes. A role is a set of expectations about how the person occupying one position behaves. Role Performance relates what a person in a particular role does to the behaviors expected of that role. Role mastery means that the person's behavior meet social expectations. Expectations, or standards of behavior of a role, are set by society, a cultural group to which a person belongs.
(K&E p. 960)
Crisis/Hospitalization
A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in crisis is temporarily unable to cope with or adapt to the stressor by using previous methods of problem solving. People in crisis generally have a distorted perception of the event and do not have adequate situational support or coping mechanisms.
(K&E p 1025) / Anxiety r/t preoccupation AEB pt wanted to go to the playroom.
Risk for Powerlessness r/t hospitalization
Risk for Situational low Self-esteem r/t developmental changes; and control over environment
Need Data - Label S for Subjective, O for Objective Data Analysis Nursing Diagnosis
S / Allergies:Pt has no allergies. (O)
State of consciousness:
Pt is alert. (O)
Orientations: person, place, time
Pt is oriented to person, place, and time. (O)
Immediate environment
Pt is alert and oriented to immediate environment. (O)
Ability to recognize & respond to environmental hazards
Pt is able to recognize and respond to environmental hazards. (O)
Memory:
Immediate Pt was able to tell what she had for breakfast. (S)
Recent Pt was able to describe what happened to her yesterday. (S)
Ability to concentrate
Pt was able to concentrate. (O)
Pupillary responses
Pupils Equally Round and Reactive to Light and Accommodation. (O)
Senses: taste, touch, smell, pain, sight, hearing
Pt does not denote any complications with her senses to taste, touch, smell, sight, and hearing. Pt has awareness of pain. (O)
Assistive devices: glasses, lens, hearing aid
Pt does not wear any assistive devices such as glasses, contact lenses, or hearing aid. (O)
Symmetry of facial expressions, tongues, smile
Pt denotes appropriate symmetrical facial expressions, movement of tongue, and smile. (O)
Condition of hair, nails, mucous membrane of mouth, nose, tongue and conjunctiva.
Pt’s hair is smooth, clean and shiny. It is black and lustrous. Pt’s nails appeared clean and strong. They do not look fragile and there are no signs of peeling or cracking. Pt’s teeth are white and clean. Her gums are pink and even. Lips are symmetrical and not dry. (O)
Condition of skin:
Skin was warm to touch, clean, dry, intact. There are no rashes or lesions visible. Good skin turgor. No diaphoresis or flushing of pt’s skin. (O)
I.V. sites, dressings, scars, rashes, nodules, ecchymosis
No I.V. site was present. (O)
Condition of breasts: symmetry, contour, puckering, nippledischarge, gynecomastia
Unable to assess (O)
Comfort status
Pt stated that she was feeling comfortable, and that had no pain. (s)
Fluid balance: I & 0 x 2 days, skin turgor, rapid weight gain or loss.
Unable to assess. Pt was not on strict I&O. Pt voided normally, and presented good skin turgor. (O)
Lab: electrolytes, WBC, culture reports, liver function tests
Lab results were not available. (O)
Body temperature patterns x 2 days
10-28-2006
1000 / 1400 / 1800 / 2200 / 0200
98.6 / N/A / N/A / N/A / N/A
10-28-2006
1000 / 1400 / 1800 / 2200 / 0200
N/A / N/A / N/A / 99.0 / 98.6
Recent exposure to infections
There were no recent exposures to infections. (O)
Medications: risks associated with side effects/interactions
1. Albuterol 0.25ml (0.5%) soln inh via Neb q2h at default.
Discharge Planning
Ability to manage health problem (s) : knowledge base,motivation, constraints, role of significant others,affiliation with PMD, clinic, affordability of medications, supplies & equipment, teaching needed
Pt and parents are motivated about pt’s health, and they hope this will be the last time they’re in the hospital.
Immunizations
Pt has had all immunizations up to her age. / Respiratory Failure
Respiratory failure occurs when the body can no longer maintain effective gas exchange. The physiologic process that ends ins respiratory failure begins with hypoventilation of the alveoli. Hypoventilation occurs when the body’s need for oxygen exceeds actual oxygen intake, the airway is partially occluded, or the transfer of oxygen and carbon dioxide in the alveoli is disrupted. This disruption may occur either because of a malfunction of respiratory center stimulation or because the alveolar membrane is defective.
(London et al, p 1394)
Asthma
Asthma is a chronic inflammatory disorder of the airway with airway obstruction that can be partially or completely reversed, and increased airway responsiveness to stimuli. Inflammation causes the normal protective mechanisms of the lungs (mucus formation, mucosal swelling, and airway muscle contraction) to react excessively in response to a stimulus and cause airway obstruction. The stimulus, or trigger, that initiates an asthmatic episode can be inflammatory or noninflammatory. Triggers increase the frequency and severity of smooth muscle contraction, and airway responsiveness is enhanced through inflammatory mechanisms. Bronchial constriction, airway swelling, and production of copious amounts of mucus causes airway narrowing. Mucus clogs small airways and traps air. The airways swell, creating muscle spasms that may become uncontrolled in the large airways. Decreased perfusion of the alveolar capillaries results from hyperinflation of the alveoli. Hypoxemia leads to an increased respiratory rate, but less air is breathed per minute because of airway resistance. Progressive chronic inflammatory changes result in airway remodeling, an irreversible thickening of the basement membrane, airway smooth muscle hyperthrophy, and mucus gland hypertrophy.
(London et al, p 1413) / Ineffective Health Maintenance r/t inability to make deliberate and thoughtful judgments AEB pt preoccupied about her physical appearance, but not preoccupied about her illness.
Risk for Infection r/t malnutrition.
Need Data - Label S for Subjective, O for Objective Data Analysis Nursing Diagnosis
O / Activity tolerancePt is able to tolerate activity in the hospital. Pt walks and is able to tolerate activity. (O)
Orthopnea
Pt does not show any signs of orthopnea. (O)
Nails, lips, skin, mucous membranes: color/temperature
Nails presented a pinkish color, skin and lips presented a pinkish, oral mucous membranes presented a pinkish color. Both pt’s upper and lower extremities were warm to touch. (O)
Capillary refill time (normal/delayed)
Capillary refill > 3 seconds. (O)
Clubbing
No signs of clubbing were present in the pt. (O)
Pulse rate, rhythm, quality (rate pattern x 2 days)
10-28-2006 Regular, strong
1000 / 1400 / 1800 / 2200 / 0200
146 / N/A / N/A / N/A / N/A
10-28-2006 Regular Strong
1000 / 1400 / 1800 / 2200 / 0200
N/A / N/A / N/A / 149 / 120
(O)
Compare apical radial pulses
No pulse difference. (O)
Peripheral pulses: bracheal, radial, femoral, popliteal, posterior tibia, dorsal pedis/volume/compare bilaterally
Peripheral pulses were present in all extremities. Pulses were strong and regular. (O)
Shape of chest
Normal chest shape was inspected. (O)
Respirations rate, rhythm, depth, patterns, use of accessory muscles, symmetry of chest movements, rate pattern x 2 days
Normal chest shape was inspected. (O)
Breath sounds: clear, coarse, crackling, wheezing
Wheezing sounds were heard over pt’s lungs. (O)
Location of adventitious soundsLeft and right upper lobes of the lungs. (O)
Cough: frequent, infrequent, dry, loose, barking, productive, etc.
No cough was observed upon assessment. (O)
Sputum: color, tenacity, amount, color
Unable to assess. (O) / Factors Affecting Respirations/Respiratory Quality
Respiratory quality or character refers to those aspects of breathing that are different from normal, effortless breathing. Two of these are the amount of effort a client must exert to breathe and the sound of breathing. The sound of breathing is also significant. Normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse’s ear. Many sounds occur as a result of the presence of fluid in the lungs and are most clearly heard with a stethoscope.
(K&E p. 506) / Ineffective Airway Clearance r/t adventitious breath sounds AEB wheezing upon assessment.
Ineffective Breathing Pattern r/t hyperventilation AEB Hx asthma, 27 breaths per minute upon admission.
Need Data - Label S for Subjective, O for Objective Data Analysis Nursing Diagnosis
N / General appearance: muscular, wasted, emaciated, obese, normal weightPt presented a normal weight appearance. (O)
Height. Patterns of weight gain, loss
95cm 50th percentile (O)
Weight. Compare current weight with ideal weight
14.5Kg 50th percentile (O)
Condition of teeth & gums, ability to chew and swallow
Pt has all teeth intact. Gums presented a pinkish color. Pt is able to chew and swallow. (O)
Eating patterns (usual, alterations associated with illness & hospitalization)
Pt’s grandmother states that her granddaughter usually eats small frequent meals throughout the day. In the hospital, her grandmother states, she eats small meals.
Diet ordered/knowledge of /compliance
Regular diet was ordered. Pt ate about 50% of her meal. (O)
Appetite: assess intake x 2 days
Pt’s mother states that she eats small meals. (S)
Cultural/religious preferences
Cultural and religious preferences denote no influence over her regular diet. (O)
Lab: serum albumin (also consider relationship of hgb. to nutritional status)
No labs were available. (O)
Glucose levels - urine, blood: acetone in urine
No labs were available. (O)
Assistive measures for nutrition (i.e. tube feedings, TPN, etc.)
No assistive measure for nutrition were needed for the pt. (O)
Basic question: are current nutritional needs being met in terms of calories, protein, vitamin C, calcium, etc.? Provide objective data to support your decisions.
According to what was stated by the pt’s grandmother, her nutritional needs are not being met. Although pt eats frequently that all the nutritional requirement in a daily diet are being consumed(O)
If feeding by nasogastric or gastrostomy tubes: estimate caloric intake for 24 hours.
Pt was fed PO. (O)
TPN: estimate caloric intake for 24 hours.
Pt was fed PO. (O) / Nutritional Needs in Adolescence
Most adolescents need well over 2000 calories daily to support the growth spurt. When teenagers are active in a variety of sports, these requirements increase further. Because adolescents prepare much of their own food and often eat with friends, they need to be taught about good nutrition. Developing a diet that includes a large number of calories, meets vitamin and mineral requirements, and is acceptable to the teen may be a challenge.
(London et al, p 1413) / Deficient knowledge: Nutritional Needs r/t unfamiliarity with information resources AEB pt’s mother is not aware of nutritional requirements for her daughter’s age.
Two priority Nursing Diagnosis with Outcomes and Implementation.