Student Name: XYZ 1

THE WILLIAM PATERSON UNIVERSITY OF NEW JERSEY

COLLEGE OF SCIENCE AND HEALTH
DEPARTMENT OF NURSING

NURSING CARE PLAN

Patient’s Initials: S.W. Date: xx/xx/xxxx

Primary Diagnosis: Lung cancer, sepsis, pneumonia Patient’s Age: 57 Room Number: 470-1

Lung Cancer

Incidence: Lung cancer is the leading cause of cancer death in both men and women in the United States. Increases in its incidence closely coincide with increase in cigarette smoking. It is

estimated that 87% of lung cancers are attributable to smoking. (Monahan, F., Sands, J., Neighbors, M., Marek, J., & Green, C., 2007, p.643) The American Cancer Society estimated that in

2005 172,570 people was diagnosed with lung cancer and 163,510 would die from the disease. Lung cancer is the third most common type of cancer in the United States, after breast cancer and

prostate cancer. Only 10% to 15% of people who develop lung cancer survive 5 years after diagnosis. (Monahan et. al, 2007, p.643) The rate of mortality for male cigarette smokers is more than

double that of nonsmokers and for females smokers it is 67% higher compared to nonsmokers. Since smoking is a primary determinant of having the cancer it also follows that a history of

smoking, especially for more than 20 years increases the chances of cancer significantly. (Monahan et. al, 2007, p.643).

Etiology: More than 90% of all lung cancers fall into four major histologic types: adenocarcinoma, large cell and squamous cell carcinoma, and small cell lung cancer. Small cell cancer grows

the most rapidly and is the most responsive to cytotoxic chemotherapy. (Monahan et. al, 2007, p.643) Lung cancer can affect other systems in the body when metastasized to structures such as

the brain, liver, kidneys, adrenal glands or skeleton. (Monahan et. al, 2007, p.646) For patients with non-small cell lung cancer the size of the tumor and degree of metastasis determines the

prognosis. As with other cancer, lung cancer is measured in stages. The two stages are limited and extensive. Limited stage indicates the tumor is confined while extensive indicates metastasis.

Metastatic tumors may follow malignancy anywhere in the body, including the colon and the kidneys, sites that are very common to metastasized lung cancer. (Monahan et. al, 2007, p. 643)

While the tumor may be discovered before reaching the stage of affecting other system, sometimes its location will not be evident until it is found only at autopsy. (Monahan et. al, 2007, p. 643)
Student Name: XYZ 2

Signs and Symptoms: Individual patient’s signs and symptoms vary and depend on several factors. One of these factors includes the location of the lesion in the lung. In approximately 10% of

cases, patients are asymptomatic and the cancer is identified on a routine chest x-ray film. (Monahan et. al, 2007, p.646) Of the symptoms that are evident, approximately 75% have a cough and

approximately 50% have hemoptysis. Shortness of breath and wheezes heard on auscultation are also common. If lesions have perforated into the pleural space, patients might also show signs of

pain on inspiration, friction rub, pleural effusion, edema of the face and neck, fatigue and clubbing of the fingers. (Monahan et. al, 2007, p.646) As the disease progresses other systems in the

body begin to break down and affect the overall health and weight of the individual.

Treatment: The collaborative care approaches to a patient suffering from lung cancer include surgical intervention, medications, and chemotherapy concurrently with radiotherapy. Surgical

interventions must be discussed with risk and benefits fully weighed. Patient’s age, pulmonary reserve, and presence of cardiovascular disease might increase the chance of post-op

complications. (Monahan et. al, 2007, p.648) Mortality and morbidity rate increases with age when performing a surgical intervention for cancer of the lung patients. Therefore ABG and PFTs

are used to measure pulmonary reserve to determine operability. If a decision is made to operate an exploratory thoracotomy confirms the diagnosis of lung or chest disease. (Monahan et. al,

2007, p.650) Afterwards the approach to the type of thoracic surgery that will be used is determined by the extent of metastasis and location of the cancer. Pneumonectomy, or removal of a

lung, or a lobectomy, a removal of one lobe, can be performed along with resections (removal of one or more segments) and decortication (removal of fibrous peel from the pleura). (Monahan et.

al, 2007, p.650) Aside from surgery, radiotherapy concurrently with chemotherapy is also used because it appears to improve survival rate for patients. However it also does increase the risk of

immune system suppression. Finally a group of medications that are cytotoxic can be used in lieu of chemotherapy to extend the survival time of patients. These drugs are a good candidate for

patients that have minimal weight loss, less extensive disease spread, and adequate functionality. (Monahan et. al, 2007, p.648) The approaches discussed, once again, have to take into

consideration the degree and severity of each patient before a treatment plan is administered.

Diagnostics: Confirmed diagnosis of lung cancer requires examination of the tumor. Specimens must be obtained through bronchoscopy, transthoracic needle biopsy, or surgery. Less invasive

procedures such as CT scan and MRI can help differentiate underlying mass from atelectasis or inflammation. A PET scan can aid in diagnosing metastatic sites if cancer is present. (Monahan

et. al, 2007, p.649) An invasive procedure such as a bronchoscopy yields a more definitive finding. Bronchoscopy is used to obtain tissue from the central tumor but can also brush and wash the

peripheral lesions. A transthoracic needle biopsy and surgery can be used to diagnose malignancies in peripheral lung nodules. Another type of diagnostic test is the cytologic analysis of sputum
Student Name: XYZ 3

that can be used to diagnose lung cancer. It is considered the safest and least expensive of the tests. Simple sputum is analyzed for bacteria and cancer cells to determine the presence of cancer.

(Monahan et. al, 2007, p.649)

Past and Concurrent Medical History

The patient is a 57 year old Caucasian female with a history of COPD. She smoked 1 pack a day for 38 years but claims to have had no significant medical problems. When asked if she

suffered from hypertension, diabetes, stroke, etc. the patient claims that aside from the seasonal cold and flu, she remained mostly healthy throughout her life. She was diagnosed with non-small

cell lung cancer in June of 2007 and has then only quit her smoking habit. The patient did admit that she did suffer from stage I hypertension but has since lowered her blood pressure without

any blood pressure medication. She had an open reduction internal fixation to treat a fractured femur in 2005. Her ongoing chemo and radiotherapy have not “affected her much” as she only

slightly lost weight. She also claims that the side effects of the treatment are minimal with only slight feeling of nausea and vomiting. Her history does include leukocytopenia and

thrombocytopenia which required the administration of Neupogin to increase her leukocytes. Her hematologic problems have been from the cancer as she indicates that she has not had problems

with her blood any other time in her life. The patient states that she has no heart problems aside from the hypertension previously mentioned but has now resolved, according to her, and denies

any history of drug use. Prior to her diagnosis of cancer she saw her doctor once a year and lived an “uneventful life”. The patient has also indicated that she drank alcohol for many years but

was for the most part social drinking. During her divorce however she indicated that she used alcohol as a means to cope. But after establishing a mutual understanding with her husband, had

decreased alcohol consumption to levels before she had gotten a divorce. The patient does not take OTC drugs or use herbal supplements according to her. She takes the occasional antacid for

stomach upset especially during her treatment phase. The dietician has instructed her to eat high calorie, high protein to bring her weight to optimal levels in order for her to fight off possible

infections. The patient was admitted to the hospital because of chest pain and shortness of breath. Following examination it was determined that she had pneumonia and sepsis, both treated with

antibiotics on an inpatient basis.

The initial goal of the medical care given to her on admission was to treat the infection in her lungs and prevent further spread of the infection in her body. The medications that are currently

in their treatment regimen are:

Student Name: XYZ 4

1. Zithromax 250mg PO daily – antibiotic: macrolide antibiotic (semisynthetic)

2. Xanax 0.5mg PO BID – anxiolytic, benzodiazepine, controlled substance schedule IV

3. Oxycontin 60mg PO BID – opioid analgesics, central nervous system drugs, controlled substance schedule II

4. Zosyn 4.5g IV q12h – penicillin, anti-inefectives, extended-spectrum penicillin, beta-lactamase inhibitor

5. Mucinex 5ml PO q12h – expectorant and antitussive, propanediol derivative, respiratory tract drugs

6. Albuterol 2.5mg + Atrovert 0.5g + Mucomyst 2cc q6h – respiratory drug therapy to decrease inflammation, dilate bronchioles, ease respiratory effort

7. Percocet 2 tab PO q6h/PRN pain – pain reliever, combination drug, 325mg acetaminophen/2.5m oxycodone hydrochloride

8. Robitussin 5ml PO q6h/PRN cough – expectorant and antitussive, propanediol derivative, respiratory drugs

Patient’s Initials: S.W. Date: xx/xx/xxxxx

Primary Diagnosis: Lung cancer, sepsis, pneumonia Patient’s Age: 57 Room Number: 470-1

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Physiological: Adequate oxygenation to Electrolyte balance Wants to know who is in
Alert and Oriented x3 A
Oxygenation CNS Negative brain trauma the room with them
Sympathetic nervous
Increased systemic BP 148/84 R/T increased
BP 148/84 I system response causing History of smoking
vascular resistance systemic resistance
vasoconstriction of arteries
Pulse: Right Radial 90 bmp
Proper SA node Adequate expansion & No signs of pathological
Left Radial 92 bmp A
functioning recoil of arteries disease
Regular rhythm
Chest appearance: bilateral, A Adequate chest structure High compliance of both Posture
Student Name: XYZ 5

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
symmetrical expansion lungs
Crackles noted in lower
Wheezes noted in lower lobes Air trapped in alveoli Cancer cells metastasized
I Impaired gas exchange lobes bilaterally R/T
bilaterally during exhalation causing obstruction in lung
impaired gas exchange
Resp rate: 18
Labored breathing w/ dry
Regular rhythm Alveoli inflamed causing
I Impaired ventilation Environmental allergens cough R/T impaired
Labored breathing with dry cough air trapping
ventilation
Use of accessory muscles to cough
Skin: good color, warm Adequate peripheral Adequate blood circulation Comfortable room
A
Nail bed refill: < 3 secs perfusion Adequate hydration temperature
Heart sounds:
Aortic & Pulmonic valves: S2 > S1 Proper timing and closing Autonomic nervous system Negative history of disease
A
Erb’s Point: S1=S2 of heart valves functioning pathology
Negative murmurs, clicks, rubs
Lab values: Inadequate erythropoietin
RBC production low R/T
RBC: 2.37 (norm 4.00 - 5.33) Decreased bone marrow production Effect of infection
I decreased bone marrow
Hgb: 8.1(norm 12.0 - 16.0) production of erythrocytes Compromised kidney spreading to kidneys
production of erythrocytes
Hct: 23.9 (norm 36.0-46.0 % ) functioning

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Physiological: Height: 5 ft 6 in
Caloric intake equal caloric Functioning hypothalamus Diet
Nutrition Weight: 131 lbs A
expenditure mechanism Genetics
BMI: 21 (Ideal BMI is 18.5 -24.9)
Appetite: desires food A Responds to hunger Functioning hypothalamus Likes hospital food
Breakfast: 20% mechanism
Lunch: 60%
Dinner: 100%
Student Name: XYZ 6

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Oral Cavity:
Lips smooth, no lesions
Mucous membranes smooth, pink,
moist
Chews and swallows without effort
Denies allergic reaction to food
Yellowing of teeth
Signs of dental fillings
Focal Contextual Residual
Functioning salivary
Adequate hydration
glands (Parotid glands,
A Adequate knowledge of Doesn’t use drugs
submandibular, sublingual,
oral care
and buccal)
Adequate tongue mobility Cranial nerves V, IX, X, No history of esophageal
Adequate amount of teeth XII intact and functioning disorders
Upper esophageal
A
sphincter intact &
functioning
Mandible intact
Allergen does not trigger
Normal immune system Not exposed to all types of
A body to respond to
functioning food
invasion
Teeth discoloration and
Chemicals in cigarettes
I Cigarette use for 38 years Lack of concern about teeth plaque formation R/T
affect integrity of teeth
cigarette use for 38 years

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Physiological: Diet intake
Abdomen: soft, non-distended, non- Functioning
Elimination Intact autonomic nervous Adequate hydration
tender A gastrointestinal reflex
system Negative history of
Bowel sounds present in all quadrants systems
pathology
Bowel elimination once a day A Rectal sphincter Defecation reflex Adequate fluid intake
Negative change in bowel movement functioning and within full functioning Adequate peristalsis
or frequency control of patient Sensory nerve fibers in
rectum intact
Student Name: XYZ 7

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual

Urine: yellow, clear

Urinalysis:
pH: 7.1 (norm 4.6 – 8)
Sp. Grav: 1.015 (norm 1.010 – 1.025)
Adequate glomerular Adequate hydration Negative history of renal
Glucose: negative A
filtration Adequate renal function pathology
Blood: Negative
Ketones: trace
BUN: 8 (norm 7-17)
Creatinine: 0.900 (norm 0.7 – 1.2)

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Able to perform activity of daily living Absence of pain upon
without assistance Intact musculoskeletal movement Loves to do everything
A
ROM coordinated system Bone strength and muscle herself
Muscle strength is WNL strength adequate
Physical stability: Adequate bone strength
Physiological:
Balance and coordination intact Absence of pain
Activity and Rest A Cranial nerve VIII intact No pain
Demonstrates shortness of breath upon Proper body alignment
exertion Electrolyte imbalance
Interrupted sleep process
Interrupted sleep process (3-4 hours of Pain during coughing Increased pressure on Concerned about what the
I R/T pain during coughing
sleep while condition persists) episodes thoracic cavity future holds
episodes
Student Name: XYZ 8

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Knowledgeable about
Skin warm, dry and appropriate for Adequate peripheral Capillary perfusion
A proper skin care and
race perfusion functioning adequately
hygiene
Able to perceive pain and changes in Intact neurologic
A Intact receptors on skin No head trauma
temperature functioning
Adequate circulation
Skin turgor resilient A Adequate hydration Fluid volume balance Diet
systemically
Physiological: Effective dissipation of
Protection Evaporation from skin aids
Body temp: 98.9°F A heat produced by Heater in room functioning
in heat loss
metabolism
I.V. #22 heplock on left
Integrity: I.V. #22 heplock on left No signs of infiltration thoracic area below
Functioning immune Proper skin care
thoracic area below clavicle A/I No sign of formation of clavicle C,D,I R/T negative
system response Proper insertion of needle
Clean, dry, and intact hematoma signs of infiltration or
hematoma
Adequate production by Functioning lymphatic
WBC: 10.5 (norm 4.5 – 11.0) A Infection subsiding
bone marrow system

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal
Physiological: Vision: Patient states able to see “fine” Natural curvature of eye
The Senses and denies need for corrective lenses A promotes optimal light
utilization
No problems with hearing A Intact internal and external
ear mechanism
Contextual Residual
No history of trauma to the
Cranial nerve II intact
eyes
Cranial Nerve VIII intact Negative history of head
and functioning trauma or significant ear
infection
Student Name: XYZ 9

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Able to perceive touch, temperature Cranial Nerves I, V, IX
changes, and pain stimuli CNS functioning properly intact and functioning
Patient’s cerebral
Identifies smell in environment easily Able to perceive stimulus
A functioning has not been
and distinguishes between taste as coming from sensory
compromised
evidenced by desire for “good-tasting” neurons
foods.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Mucous Membranes: pink, moist
Skin tugor resilient
Physiological:
Fluid & Electrolytes
Alert and Oriented x3
Lab values:
Na 142 (norm 137 – 145)
K 4.1 (norm 3.5 – 5.0)
Cl 105 (norm 98 – 107)
Ca 8.5 (8.4 – 10.2)
Focal Contextual Residual
Functioning salivary
glands (Parotid glands,
A Adequate hydration No history of drug use
submandibular, sublingual,
and buccal
Adequate circulation Uses daily moisturizing
A Adequate hydration
Skin intact cream
Awake during time of day
Adequate oxygenation to Functioning medulla
A Alert to presence of
CNS oblongata
individuals in room
Essential ions filtrated and
Negative history of renal
A conserved at nephrons of Adequate renal function
pathology
kidney

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Physiological: Cranial Nerve I: A Intact cranial nerve Clean and clear nasal No history of injury to nose
Neurological Function Able to smell and identify smells cavity No history of serious nasal
Student Name: XYZ
Mode & Subdivision Behaviors
Cranial Nerve II:
Denies problems with vision or need of
corrective lenses.
Cranial Nerve III:
Pupils and extraocular eye movement
equal
Consensual constriction and light
accommodation
Cranial Nerve IV:
Even, smooth, symmetrical movements
of both eyes
Cranial Nerve VI:
Able to laterally rotate the eyes
Cranial Nerve V:
Able to perceive touch, pain, and
thermal changes in the face
Able to chew food easily
Cranial Nerve VII:
Even, symmetrical movements of face
muscles
Able to perform wide variety of facial
expression without needed effort
Ability to different flavor profiles
(sweet, salty, sour, bitter)
Cranial Nerve VIII:
Patient does not display hearing
10
A/I Stimuli Nursing Diagnosis
Focal Contextual Residual
Nasal secretion production
infections
within normal limits
Doesn’t expose eye to
A Intact cranial nerve Corneal lenses intact
harmful radiation
Muscles responsible for
A Intact cranial nerve No eye injury
ocular movement intact
Intact sensory-motor
receptors Negative history of injury to
A Intact cranial nerve
Adequate mandible face
strength
History of stroke has not
Intact facial muscles
A Intact cranial nerve affected significant areas of
Intact taste buds
brain
A Intact cranial nerve Intact cochlea & vestibule Cleans her ears properly
Intact internal and external daily
Student Name: XYZ 11

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
ear
problems or balance and coordination Negative sign of cerumen
impaction
Cranial Nerve IX:
Patient is able to swallow fine
Patient gags when gag reflex is elicited
Intact stylopharyngeus
No history of esophageal
A Intact cranial nerve muscle
Cranial Nerve X: disease
Intact pharynx & larynx
Patient demonstrates ability to
swallow, cough effectively, and speech
does not cause problems or fatigue
Cranial Nerve XI:
Even, symmetrical movement of the
Intact trapezius & No sign of paralysis to
head
A Intact cranial nerve sternocleidomastoid upper extremities of the
Negative signs of limited ROM or
muscle body
difficulty when asked to perform ROM
of neck test
Cranial Nerve XII: Intact cranial nerve
Full control of movement of tongue History of stroke has not
Tongue movement within
No difficulty of speaking A affected movement of
full control
Tongue does not deviate in one tongue
direction when protruded

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Physiological: Growth & development WNL for age A Proper growth hormone Functioning pituitary gland Genetics
Endocrine regulation Adequate calcium intake Diet
Negative history of
osteoporosis
Student Name: XYZ 12

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Functioning ovary gland
Secondary sex characteristics WNL A Proper estrogen regulation Genetics
Functioning pituitary gland
Diet intake
Abdomen: soft, non-distended, non- Functioning
Intact autonomic nervous Adequate hydration
tender A gastrointestinal reflex
system Negative history of
Bowel sounds present in all quadrants systems
pathology
Sympathetic nervous
Increased systemic BP 148/84 R/T increased
BP 148/84 I system response causing History of smoking
vascular resistance systemic resistance
vasoconstriction of arteries
The behaviors assess above revealed the patient suffered mostly from the oxygenation mode. The main concern was the inflammation of lower airways and systemic infection stemming from the
cancer in the lung.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Body Sensation:
Effective compensation by body Central nervous system intact
“Even with the radiation and chemo Denying what she
A during radiation and chemo Functioning feedback loop allow
therapy, I never felt that I was sick. No actually feels
therapy session body to maintain homeostasis
Self Concept: one even knew I had cancer.”
Physical Self Body Image:
Adequate physical development
Patient states that she’s “I make sure to Feels acceptance from close Husband loves
A Erikson developmental stage
always look presentable when I’m family and friends her for who she is
achieved
going out. I like to look good always.”

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Self Concept: Self-Consistency: A Able to adapt to long term High self-esteem Not overwhelmed
Personal Self Patient states, “I try not to let my implication of cancer by current health
condition get the better of me. I take problem
each day one at a time.”
Student Name: XYZ 13

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Self-Ideal: Relies on
“I really want to go back home, but I Activity intolerance disability funds Hopelessness R/T
I Ineffective ventilation process
know I won’t be able to do the same Shortness of breath Doesn’t want to activity intolerance
things as before.” get better
Moral-Ethical-Spiritual Self:
Personal need of a higher being
Patient is Protestant and believes in A Strong belief in spiritual being Life experiences
helping patient cope
God but does not attend church.

The patient exhibited more problems than strengths in the self-concept mode. The patient illness affected his body sensation as well as his self-ideal. His coping strategies are ineffective due to
his fear of undesired situations.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Life experience
57 year old, female
Role Function: Achievement of role expectations contributed to
Mature adult A Desire to meet social standards
Primary Role of developmental stage normal
Generativity v. stagnation
maturation

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Role Function: Consumer: Children
Secondary Roles Mother Reward: Affection & close
Instrumental: Patient interacts with relationship
daughter and granddaughter that visit Access to facilities: phone,
Desires to maintain strong Raised children
her everyday. A privacy provided by staff and
relationship well
Expressive: Patient expressed roommate
gratitude for wonderful family support Cooperation & Collaboration:
system. Children visit patient everyday
in hospital
Wife A Desire to maintain strong Consumer: Husband Still cares about
Student Name: XYZ 14

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Instrumental: Patient remains in Reward: Maintain friendship and
contact with husband even though contact
husband but does
divorced. Patient claims “we are on Access to facilities: privacy
not want to
good terms.” relationship provided by nursing staff
burden him
Expressive: Patient states she does not Cooperation and Collaboration:
anymore
want to contact her husband because Full visiting rights and hours in
“it’s just going to worry him.” case ex-husband comes to visit
Consumer: grandchildren and
Grandmother great-grandchildren
Instrumental: Patient hugs, kisses, Reward: affection & close
Wants grandchild
and plays with granddaughter that relationship
and great-
visits. Access to facilities: phone and
A Enjoys presence of children grandchildren to
Expressive: Patient states, “I love all 6 visitation rights
know their
grandchildren. They make me so Cooperation and Collaboration:
grandmother
happy. Especially James, my full visitation rights for
daughter’s 2 year old son.” grandchildren and great-
grandchildren
Consumer: Husband
Unemployed
Reward: Will not be able to
Instrumental: Unable to work because
afford certain things
of physical limitations. Unable to perform arduous task Content with
Access to Facilities: Still able to Interrole conflict R/T
Expressive: “I’m living on disability I without suffering from shortness being put on
drive to supermarket, shopping activity intolerance
because of my condition. It’s very of breath or thoracic pain disability
malls, etc.
hard to work with you have difficulty
Collaboration & Cooperation:
breathing.”
Federal government

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Role Function: Sick role A Accepts medical prognosis Adequately presented all Just telling staff
Tertiary Roles Instrumental: Patient is complaint Knows things will never be the information by healthcare and to please them
with all medical orders and lifestyle same medical team
modifications.
Student Name: XYZ 15

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Expressive: “In know that I have to
change in order to keep up with my
condition.”

The patient displayed role mastery in her primary and tertiary roles but has failure in her secondary role because of her unemployment status which might affect her health maintenance.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Patient indicates that she does not have
No concern of having significant Lack of significant
Interdependence a significant other but her ex-husband Divorced for 16 years and Distrusts potential
other present in patient’s life other R/T no concern
Mode: Significant has proved supportive during her I doesn’t want to find someone husbands because
Shows concern for disturbing her about have significant
Other ordeal. However she does not want to else of life experiences
ex-husband’s life other present
bother him with her problems.

Mode & Subdivision Behaviors A/I Stimuli Nursing Diagnosis

Focal Contextual Residual
Patient has four children that range in
Very instrumental in the Does not want to
age from 43 to 37. They have their
Interdependence development of her children feel lonely
own family to take care of but still Wants to still be involved with
Mode: Support A Wants to ensure that the children Does not want to
make time for their parents, according family processes
System do not get burdened by her feel distant from
to her. Patient stated that she is a
condition family
proud grandmother of 6 grandchildren.

Nursing Diagnosis:

1. Impaired gas exchange R/T inflammation of airways and alveoli

2. Acute pain R/T to increased respiratory rate secondary to alveolar inflammation of the lungs.

3. Anxiety R/T unpredictable or unstable course of illness

Student Name: XYZ
4. Ineffective health maintenance R/T inability to identify, manage, and/or seek help to maintain health
5. At risk for fluid volume deficit R/T decreased fluid intake
6. Imbalanced nutrition: less than body requirements R/T intake of nutrients insufficient to meet metabolic needs
7. Hopelessness R/T activity intolerance
8. Impaired swallowing R/T fatigue secondary to increased energy expenditure
Nursing Diagnosis Nursing Interventions
Impaired gas exchange R/T inflammation of 1. Assess patient’s respiration: quality, rate,
airways and alveoli rhythm, depth, dyspnea on exertion, use of
accessory muscles, position assumed for easy
breathing
2. Monitor vital signs q4h
3. Monitor effects of positioning on oxygenation
levels (with the use of pulse oximetry)
4. Maintain oxygen administration as ordered to
ensure oxygen saturation 90% or greater (95%
or greater is ideal). Avoid high concentrations
of oxygen in patients with COPD
5. Encourage use of incentive spirometer
6. Administer medication as prescribed carefully
and in a timely manner
7. Use optimal positioning and encourage
ambulation
16
Rationale for interventions (Referenced) Evaluation
1. Both rapid, shallow breathing patterns and Patient demonstrates
hypoventilation affect gas exchange. Use of decreased respiratory rate and
accessory muscles to breathe indicates an abnormal calmer appearance
increase in the work of breathing. Abnormality
indicates respiratory compromise. (Gulanick, M. & Patient maintains alert mental
Myers, J., 2007, p.482) status and does not show
2. With initial hypoxia and hypercapnia, blood evidence of respiratory
pressure, heart rate, and respiratory rate all rise. As distress
the condition worsens BP and HR will drop and
arrhythmias may occur. Respiratory failure may
ensue when the patient is unable to maintain the
rapid respiratory rate needed to maintain
oxygenation. (Gulanick, M. & Myers, J., 2007,
p.366)
3. The semi-Fowler’s or high Fowler’s position allows
maximum chest expansion in clients who are
confined to bed, particularly those with dyspnea.
The nurse also encourages clients to turn from side
to side frequently, so that alternate sides of the
chest are permitted maximum expansion. (Berman
et al., 2008, p.1368)
4. Supplemental oxygen therapy maintain oxygen
saturation of 90% or greater to provide adequate
oxygenation. Careful administration of low liter
Student Name: XYZ
Nursing Diagnosis
Scientific Knowledge Base (referenced):
Pneumonia is caused by a bacterial or viral
infection that results in an inflammatory
process in the lungs. It is an infectious
process that is spread by droplets or by
contact. It is one of the most common causes
of death in older adults. Predisposing factors
to the development of pneumonia include
17
Nursing Interventions Rationale for interventions (Referenced) Evaluation
flow oxygen is indicated because hypoxia
stimulates the drive to breath in the patient who
chronically retains carbon dioxide. (Gulanic, M. &
Myers, J., 2007, p. 482).
5. Incentive spirometers measure the flow of air
inhaled through the mouthpiece and are used to
improve pulmonary ventilation, loosen respiratory
secretions, facilitate respiratory gaseous exchange,
and expand collapsed alveoli. (Berman et al., 2008,
1370).
6. Ongoing administration of antimicrobial agents
needs to be timely to maintain blood levels needed
to fight the organism adequately and prevent
relapse or the development of a resistant strain of
the organism. (Gulanick, M. & Myers, J., 2007,
p.367) Expectorants are used for productive
coughs and cough suppressants for hacking
nonproductive coughs. Bronchodilators and inhaled
steroids are used to open airway and decrease
inflammation. (Gulanick, M. & Myers, J., 2007,
p.481).
7. The sitting position and splinting the abdomen
promote more effective coughing by increasing
abdominal pressure and upward diaphragmatic
movement. Ambulation mobilizes secretions and
reduces atelectasis. (Gulanick, M. & Myers, J.,
2007, p.481)
Patient/Patient/Family goal/expected outcome: Modification
Short term goal: If patient’s respiratory rate
Patient will exhibit signs and symptoms of increases or evidence of
improved ventilation and oxygenation by respiratory distress occurs,
respiratory rate of 12 to 16 breaths/min and relaxed prepare to administer
comfortable appearance emergency bronchodilator to
open up airways and
Long term goal: corticosteroids to prevent
Student Name: XYZ
Nursing Diagnosis
upper respiration infection, excessive alcohol
ingestion, central nervous system depression,
cardiac failure, any debilitating illness, and
chronic COPD. At risk are patients who are
immunosuppressed, have a history of smoking
or who are malnourished or dehydrated.
(Gulanick, M. & Myers, J., 2007, p. 477).
Nursing Diagnosis
Acute pain R/T increased respiratory rate
secondary to alveoli inflammation of the lungs
Nursing Interventions
Patient maintains optimal gas exchange evidenced
by alert mental status and negative signs of
respiratory distress
Nursing Interventions
1. Assess pain characteristics: quality, severity,
location, onset, duration, and relieving factors
2. Observe or monitor signs and symptoms
associated with pain, such as BP, heart rate,
temperature, color and moisture of skin,
restlessness, and ability to focus.
3. Anticipate need for pain relief and respond
immediately to complaint of pain
4. Administer pain medication as ordered,
evaluating effectiveness and observing for
signs and symptoms of side effects
5. Instruct patient on relaxation exercises,
biofeedback, breathing exercises, imagery and
music therapy
6. Evaluate the patient’s response to pain and
medications or therapeutics aimed at
eliminating or relieving pain
18
Rationale for interventions (Referenced) Evaluation
further decompensation. If
patient continues to
decompensate prepare for
possible intubation and
mechanical ventilation.
Rationale for interventions (Referenced) Evaluation
1. Assessment of the pain experience is the first step Patient indicated pain level
in planning pain management strategies. Other decreased from 5 to 1
methods such as a visual analog scale or following 2 hours of nursing
descriptive scales can be used to indentify extent of intervention
pain. (Gulanick, M. & Myers, J., 2007, p.145)
2. Some people deny the experience of pain when it is Patient’s respiratory rate also
present. Attention to associated signs may help the decreased further helping in
nurse in evaluating pain. (Gulanick, M. & Myers, decreasing pain level.
J., 2007, p. 145)
3. One can most effectively deal with pain by
preventing it. Early intervention may decrease
total amount of analgesic required. Prompt
responses to complaints foster the development of a
trusting relationship with the patient. (Gulanick, M.
& Myers, J., 2007, p.147)
4. NSAIDs work in peripheral tissues. Some block
synthesis of prostaglandins, which stimulate
nociceptors. They are effective in managing mild to
moderate pain. Opiods are indicated for severe pain
and local anesthetics block pain transmission in
specific areas of nerve distribution. (Gulanick, M.
& Myers, J., 2007, p.147)
5. Techniques are used to bring about a state of
physical and mental awareness and tranquility. The
goal of these techniques is to reduce tension,
Student Name: XYZ 19

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Scientific Knowledge Base (referenced):
Pain is a highly subjective state in which a
variety of unpleasant sensation and a wide
range of distressing factors may be
experienced by the sufferer. Pain may be a
symptom of injury or illness. Pain can be very
difficult to explain because it is unique to the
individual. Pain should always be addressed
by the primary care provider. (Gulanick, M. &
Myers, J., 2007, p.144).
Patient/Patient/Family goal/expected outcome:
Short term goal:
Patient will demonstrate decreased pain level
according to 1-10 pain scale
Long term goal:
Patient will correctly identify ways to manage pain
through positioning and meditation
subsequently reducing pain. (Gulanick, M. &
Myers, J., 2007, p.148)
6. It is important to help patients express as factually
as possible the effect of pain relief measures.
Discrepancies between behavior or appearance and
what the patient says about pain relief may be more
reflection of other methods that the patient is using
to cope with than pain relief itself. (Gulanick, M. &
Myers, J., 2007, p.34)
Modification:
If blood pressure continues to decrease watch for signs
of oxygen deprivation and prepare for airway
intubation and oxygen therapy.
Prepare for defibrillation if patient demonstrates
pronounced, life-threatening dysrhytmias.

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Anxiety R/T unpredictable or unstable course
of illness
1. Acknowledge awareness of the patient’s 1. Because anxiety cannot always be identified, the Patient became calmer when
anxiety patient may feel as though the feelings experienced the doctors assured her a
2. Reassure the patient that she can have someone are not real. Assure the patient those feelings are concrete plan of care that
with her at all times. real and promote acceptance of those feelings. indicated possible discharge
3. Maintain a calm manner while interacting with (Gulanick, M. & Myers, J., 2007, p.16) from the hospital the next day.
the patient 2. The presence of a trusted person may be helpful When asked whether visitors
4. Establish a working relationship with the during an anxiety attack. . (Gulanick, M. & Myers, affected her level of anxiety
patient through continuity of care J., 2007, p.16) patient denied.
5. Reduce sensory stimuli by maintaining a quiet 3. The health care provider can transfer his or her own
environment anxiety to the patient therefore it is important to Patient’s anxiety clearly
Student Name: XYZ 20

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Scientific Knowledge Base (referenced):
Anxiety is a vague, uneasy feeling of
discomfort or dread accompanied by an
autonomic response. It is a feeling of
apprehension caused by anticipation of
danger. It is a signal that warns individuals of
impending danger and enables the individual
to respond to the threat. . (Gulanick, M. &
Myers, J., 2007, p.15)
6. Assist the patient in developing anxiety-
reducing skills (ie. Relaxation, deep breathing,
positive visualization)
7. Use simple and easy statements in explaining to
patient about condition or procedures
Patient/Patient/Family goal/expected outcome:
Short term goal:
Patient will demonstrate calmer facial expression regarding her plan of care. She needs to be assured that
and demeanor.
Long term goal:
Patient will be able to verbalize ways to minimize
anxiety through the use of effective coping
mechanism
present a calm and non-threatening atmosphere. dropped as student nurse
(Gulanick, M. & Myers, J., 2007, p.16) conversed and joked with the
4. An ongoing relationship with the patient allows patient.
open communication regarding patient’s anxious
feelings. (Gulanick, M. & Myers, J., 2007, p.16)
5. Anxiety may escalate with excessive conversation,
noise and equipment around the patient. This is
true especially in hospital settings. (Gulanick, M. &
Myers, J., 2007, p.17)
6. Using anxiety-reduction strategies enhances the
patient’s sense of personal mastery and self-
confidence. (Gulanick, M. & Myers, J., 2007, p.17)
7. When experiencing moderate to severe anxiety,
patients may be unable to comprehend anything
more than simple, clear, and brief instructions.
(Gulanick, M. & Myers, J., 2007, p.17)
Modifications:
Patient needs continued positive reinforcement
the interdisciplinary team is doing their best to alleviate
her condition.

Nursing Diagnosis Nursing Interventions Rationale for interventions (Referenced) Evaluation

Ineffective health maintenance R/T inability to 1. Assess for physical defining characteristics
identify, manage, and/or seek help to maintain 2. Assess the patient’s knowledge of health
health maintenance behaviors
3. Determine the patient’s specific questions
related to health maintenance
4. Provide the patient with rationale for
importance of behaviors such as following
1. Changing ability or interest in performing the
normal activities of daily living may be an indicator
that commitment to health and well-being is
waning. (Gulanick, M. & Myers, J., 2007, p.96)
2. Patients may know that certain unhealthy behaviors
can result in poor health outcomes but continue the
behavior despite this knowledge. The health care
Patient feels that her
respiratory problems will
keep coming back and seems
to be affected by the fact that
she will not be able to return
to her state of wellness prior
to her diagnosis of non-small
Student Name: XYZ
Nursing Diagnosis
Scientific Knowledge Base (referenced):
Altered health maintenance reflects a change
in an individual’s ability to perform the
functions necessary to maintain health or
wellness. The nurse’s role is to identify factors
that contribute to an individual’s inability to
maintain healthy behavior and implement
measures that will result in improved health
maintenance activities. The task before the
nurse is to identify measure that will be
successful in empower patients to maintain
their own health within the limits of their
ability. (Gulanick, M. & Myers, J., 2007,
p.161)
Discharge Planning
Nursing Interventions
proper nutrition
5. Involve family and friends in health planning
conferences
Patient/Patient/Family goal/expected outcome:
Short term goal:
Patient will be taught positive health maintenance
behaviors such as keeping appointments, avoiding
drugs and alcohol, making diet and exercise
changes, improving home environment, and
following treatment regiment.
Long term goal:
Patient will identifies available resources and uses
available resources for continued positive health
maintenance prior and after discharge.
21
Rationale for interventions (Referenced) Evaluation
provider needs to ensure that the patient has all of
the information needed to make good lifestyle
choices. (Gulanick, M. & Myers, J., 2007, p.162)
3. Patients may have health education needs; meeting
these needs may be helpful in mobilizing the
patient. (Gulanick, M. & Myers, J., 2007, p.162)
cell lung cancer.
4. The new MyPyramid approved by the Food and
Drug Administration provides guidance on
Patient is able to verbalize
recommended food groups across a variety of
ways to maintain positive
populations. Cardiovascular disease, cancer, type 2
health maintenance behaviors
diabetes, and osteoporosis are but a few of the
but finds it difficult at times
many medical diseases related to nutrition.
to abide by it.
(Gulanick, M. & Myers, J., 2007, p.163)
5. Family members need to understand that care is
planned to focus on what is most important to the
patient. This enables the patient to maintain a sense
of autonomy. (Gulanick, M. & Myers, J., 2007,
p.163)
Modifications:
Interdisciplinary team will continue to reinforce
materials presented to maintain positive heath
maintenance to patient. Patient must be reminded as to
the benefits of maintaining a healthy lifestyle as well as
the risk of failing to do so.
Student Name: XYZ 22

A. Has the illness experience brought changes to the patient’s role, self-concept, and interdependence? Is this a temporary or permanent health status change? Will the change affect family

dynamics/function?

As the patient clearly expressed, she hasn’t let her current condition affect her life much. As a 57 year old independent individual, she still carries on her day to day life to the best of

her abilities. Her role now has changed from working a full-time job to relying on disability funding from the government. However she does not feel that her view of herself has

changed. As she stated, “I really won’t let this cancer get the better of me.” The patient doesn’t like to be dependent on anyone because of her strong personality, but she has

indicated that her daughter knows that she will need more assistance now that her condition has deteriorated. As a stage IV cancer patient, she knows that her disease will cause

further problems in the future, and she has accepted that reality. Although the patient tries to cope with the prospect of dealing with her condition and attempts to hide her anxiety, it is

evident in her conversation with staff and visiting family members. As for her family, the daughter claims they haven’t been quite affected because as she said, “Our mom is really

strong. She’s going to get through this with or without our help. It’s up to her how much we should get involved.” The patient has said that she will try to do everything herself to the

best of her ability, and will only ask for assistance if absolutely necessary.

B. Identify what criteria serve as the basis for determining readiness for discharge of this patient from the acute care setting.

After speaking with the case manager, the discharge plan for the patient is to go home with follow-up respiratory rehabilitation on outpatient basis. The doctor spoke with the patient

as to the importance of avoiding activities that might cause another infection. The nurse must assess vital signs to ensure stability. Lung sounds must also be clear before discharging

the patient to ensure that her respiration is no longer compromised. In addition to this the patient must have adequate discharge teaching to prevent further incidence of hospitalization

due to another infection. In collaboration with the dietician, the patient must be taught how to manage her diet to ensure her metabolic needs are met and essential nutrients are

absorbed by the body to help strengthen her immune system. Furthermore the interdisciplinary team must be wary of the required follow-up visits by the patient after being discharge

to home, especially since her therapeutic regiment will be ongoing.

C. What measures did you take to promote an effective discharge transition by the patient/family in this situation?
Student Name: XYZ 23

Speaking with the case manager, primary physician, respiratory therapist, and dietician I was able to determine an effective transition means for the patient. Once the patient is stable

and ready to go home, I must ensure that she has the necessary support system to assist her with her daily needs and to make sure those medications that she will continue to take are

fully explained to her. Because the patient will be discharge to home, and she is a 57 year old individual that is more than capable of taking care of her ADLs, my main concern lay

with her knowing how to maintain a high degree of wellness after discharge. Because she will continue to receive therapy for her cancer and further respiratory rehabilitation

afterwards, I must reinforce with the patient the importance of keeping to her scheduled appointments on the outpatient basis. Nutrition and avoiding infection was top priority in

discharge teaching for the patient. Her cancer therapy regiment has weakened and will continue to weaken her immune system so avoiding instances where she might acquire another

infection from the community was top priority in discharge teaching. Furthermore, her nutritional status discussed ways for her to consume high calorie and nutritionally dense foods

to meet her metabolic demands as well as provide her with the necessary vitamins and mineral to strengthen her body during her cancer therapy. The patient had to understand all

these before an effective discharge from the hospital could take place.

D. What actions/interventions contributed to the safe discharge of the patient?

The only way for the patient to be safely discharged from the hospital is for the whole healthcare team to collaborate in the care of the patient. These included anticipatory teaching by

the nurse, consulting with the case manager for the best place to discharge patient, treatment explanation by the respiratory therapist, and nutritional assessment by the dietician. As

the student nurse, I had to present this to the patient in such a way that facilitated understanding. Anticipatory teaching was foremost and reinforcement of materials taught became top

priority. As the student nurse in charge of the patient, positive reinforcement became top priority and the patient had to understand her treatment regiment must be followed in order to

ensure a high degree of wellness even during her cancer treatment regiment. Once the patient adequately identified positive health maintenance behaviors the treatment team can rest

assured that the patient can be safely discharged.

References:

Andrews, H. & Roy, C. (1999). The Roy Adaptation Model. Stamford: Appleton & Lange.
Student Name: XYZ 24

Berman, A., Erb, G., Kozier, B., & Snyder, S. (2008). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. Upper Saddle River: Pearson Prentice Hall.

Carpenito-Moyet, L. (2008). Handbook of Nursing Diagnosis. Philadelphia: Lippincott Williams & Wilkins

Gulanick, M., & Myers, J., (2007). Nursing Care Plans: Nursing Diagnosis and Intervention. St. Louis: Mosby Elsevier.

Monahan, F., Sands, J., Neighbors, M., Marek, J., & Green, C. (2007). Phipp’s Medical-Surgical Nursing: Health and Illness Perspectives. (8th ed.) St. Louis: Mosby Elsevier.

Lewis, S., Dirksen, S., Heitkemper, M., O’Brien, P., & Bucher, L. (2007). Medical Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis: Mosby Elsevier.

Holloway, N. (2004). Medical-Surgical Care Planning. Springhouse: Lippincott Williams & Wilkins.