[Institution Title]
Care Plan Template
Patient Initials: N/A Age: 65 years old Sex: Female
Subjective Data:
HPI (History of Present Illness): According to the patient her cough started two weeks prior to medical attention. She also mentioned she experienced shortness of breath and feeling tired after physical activity. Two days ago, patient started to develop fever which registered at 101°F.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): Patient recalled that as a child she had asthma. She was also initially diagnosed with emphysema, for which she was treated with antibiotics and inhaler. Patient also had a hysterectomy during the 70’s. Patient has allergy for sulfa drugs which caused her to develop rashes. Patient is not taking any medication on a regular basis. However she also admitted to taking two Tylenol (650mg) for pain whenever needed.
Significant Family History: Patient also has two older siblings—both sisters who are in their 70’s. Her eldest sister has osteoporosis, while the younger sister has breast cancer.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use) Patient used to be a hairdresser prior to retirement. Although patient is living off her retirement, she has her own house and enough savings in the bank. Patient is also a church goer. She regularly participates in church activities. Patient said she is not involved in any kind of physical activity because she feels exhausted after physical activity. On her free time, patient does her hobby which is sewing. Patient also admits to smoking a pack of cigarette daily for the past forty years. Although patient likes to believe that she has a healthy diet.
Description of Client’s Support System: Patient has two daughters. They are both living near her. Both are alive and are doing well. Despite their geographical closeness, patient reports that she only sees her daughters once a month. Patient has a care provider who sees her at least three to four times a year. She also has friends from the Church but none of them she hangs out with or talk to outside the Church.
Behavioral or Nonverbal Messages: Patient verbalized to have been experiencing depression. She says she has no one to communicate with or go shopping with when she is bored. Patient expresses desire for company.
Objective Data:
Vital Signs including BMI:
Patient’s blood pressure is 130/72 and temperature is 101°F. Both findings are not within the normal range. Patient’s BMI was computed at 30.2. The patient’s BMI is classified under obese since the normal BMI should only be 30. RR and PR are identified as normal.
Physical Assessment Findings: Normal findings on PA except for the decrease breathe sound, increase anterior-posterior diameter of the chest wall. Also there was a significant finding of white material on the buccal mucosa on patient’s tongue which cannot be removed by a tongue blade. This is suspected to be caused by a fungi.
Lab Tests and Results:
WBC = 15,000 left shift, Pulse oximeter reading = SAO2 98%.
Patient refuse to be tested in nearly every recommendations she was advised with.
ICD-9 Diagnoses/Client Problems:
According to ICD-9, patient is diagnosed with the following: 4928 – Other emphysema, 27800 – Obesity, unspecified and V790 - Screening for depression
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
- Point of Concern: Patient manifests unhealthy behavioral practices relating to habits, i.e. smoking cigarette
- Smoking one pack of cigarette daily
Nursing Intervention:
- NIC 4490 Smoking cessation – patient should stop smoking. May necessarily require to introduce patient to measures that could assist patient to smoking depending on which is effective to her like a nicotine patch. (Rationale: Patient should stop smoking because it can aggravate her existing medical condition)
- NIC 4360 Behavior modification – assist patient towards behavioral change. Need to educate patient that her smoking habits are posing real health risks. (Rationale: This behavior poses great risk to her health and may cause serious problems particularly obstruction to her breathing).
- Obesity, Unspecified
Nursing Intervention:
- NIC 1260 Weight Management –Patient’s BMI registered at 30.2. Thus, patient need to manage her weight. She was on a healthy diet according to her. There must be the need to have her document her daily food intake and have a dietician evaluate it to give her the proper diet. (Rationale: Patient might not know what exactly are considered healthy foods and while patient could be eating healthy, the proportion of servings might be too much).
- Point of Concern: Subject patient to active health practice and health patterns
Nursing Intervention:
- NIC 6520 – Health Screening. Patient has repeatedly decline getting screened for any possible illness associated with her symptoms. However, patient should be taught that this is needed for early treatment to prevent any possible risk. (Rationale: If the patient is not appropriately screened for the right health concern, they might end up curing something that does not exist or it could aggravate an existing condition).
- Point of Concern: Ineffective Coping Mechanisms
Nursing Intervention:
- NIC 7110 Family Involvement Promotion – Facilitate family participation. Might need to talk to patient’s children to get involved in their mother’s life. (Rationale: this could relieve patient’s anxiety and depression. These people could also help motivate the patient to stop smoking and subject to health screenining.)
- Point of Concern: Airways and breathing management
Nursing Intervention:
- NIC 3350 Respiratory Management – patient reports difficulty in breathing. May necessarily refer the patient to a Respiratory Therapist.
(Rationale: Respiratory management can help monitor whether client is experiencing any indications of hypoxia which can poses serious implications is not managed adequately.
References
National Health, Lungs and Blood Institute. (2014, November 5). Aim for a Healthy Weight. Retrieved from National Health, Lungs and Blood Institute Website: http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
National Institute of Mental Health. (2014, November 3). Depression. Retrieved from National Institute of Mental Health Website: http://www.nimh.nih.gov/health/topics/depression/index.shtml
