Nursing Care Plan: Patient N.Z., Research Paper Example

A nursing care plan is important to the effective treatment of a patient. The nurse is the main source of care that is given to a patient, as dictated by the attending physician. Developing a nursing care plan based on the patient’s physical needs, diagnosis, mental and emotional state is vital to the continuity of care of the patient. Careful documentation is required for continual delivery of nursing care given from shift to shift. The assessment criteria and pathology is essential to the overall nursing care plan. Ms. N.Z. is a patient with multiple problems and an ideal candidate for demonstrating the importance of careful planning, documentation and continuity of care.

Patient

Ms. N.Z. is a 65 year old, white, married female. Her husband is living and accompanies her on visits. She has two grown children and three grandchildren. She is a retired teacher of the deaf. Since retirement three years ago she volunteers at surrounding hospitals interpreting for deaf patients, staff and visitors.

History

Ms. N.Z. presented for an annual examination with her physician due to excessive fatigue problems. An elevated calcium level was found on lab work. A thyroid scan was ordered which resulted in the finding of a nodule. Needle biopsy performed revealed this to be a benign nodule. Despite removal of the nodule the patient presented again to her physician with persistent fatigue with the addition of fever and right flank pain. The physician ordered a CT scan of the abdomen which revealed a left lower lobe mass.

The patient subsequently underwent VATS left lower lobectomy. One week later the patient presented to the emergency room with pain in the right upper quadrant. After exhausting suspected pancreatitis due to an elevated lipase level, another CT scan was performed demonstrating pleural effusion. Thoracentesis was performed with fluid drainage and subsequent continued accumulation of fluid. Due to the continued drainage the patient was taken back to the operating room where two chest tubes were place for drainage of the effusion.

Family History

There is a strong family history of Factor V Leiden. One sister has melanoma and another with breast cancer and hypertension. One sister and mother has Graves’s disease. Her father has gout and diabetes II.

Past Medical History

Ms. N.Z. has a past history of Factor V Leiden, hypertension, hypercholesterolemia, asthma, urinary tract infections, renal stones, anxiety disorder and left lower lobe mass.

Past Surgical History

The patient has had a laryngoscopy with tonsillectomy and exploration of the neck in 2009, arthroscopic surgery of the right knee in 2005 and the left ankle in 2000. She has had multiple hand surgeries and a video-assisted thoracoscopic surgery of the left lower lobectomy this past August, 2009.

Medication Allergies

Ms. N.Z. is allergic to sulfa drugs, hydrocodone, tegaderm, chocolate flavoring and she is lactose intolerant.

Home Medications

Albuterol 1 puff q.4.h. Clonazepam 1 mg p.o. p.r.n. This was given for anxiety following her surgery. Advair 1 puff b.i.d. p.r.n. Singulair 10 mg p.o. h.s. Valsartan 80 mg p.o. q.d. Colace 100 mg p.o. q.d. Nexium 40 mg p.o. q.d. Darvocet N100 2 tabs q.6.h. p.r.n.  pain

Hospital Medications

In addition to her home meds, in the hospital the patient is also on Dilaudid IV, Ondansetron, IV fluids 0.9% NaCl, Versed IV and Fentanyl IV.

Pathology

Pleural effusions are small amounts of fluid present in pleural spaces, typically not detectable by routine methods (National Lung Health, 2000). This problem affects the body organs and functioning in creating accumulation of fluid in the lungs; creating health risks for the patient. The patient will experience chest pain and pressure, dyspnea with cough. Chest pressure usually does occur until the effusion is in the moderate to large category (500-1500 ml to greater than 1500 ml) (National Lung Health, 2000). “Dullness to percussion and tactile fremitus are the most useful findings for pleural effusion” (Wong, Holroyd, & Straus, 2009).

Noninvasive diagnostic techniques are helpful in correct diagnosis and treatment plan. Chest x-ray and chest CT provide the modalities for distinguishing between parenchyma and pleural disease. Thoracentesis and pleural fluid analysis are the typical methods for treatment and preventive measures for pleural effusions. Not all effusions need to be tapped, however, when the patient has no obvious clinical cause the fluid should be removed (National Lung Health, 2000).

Diagnostic thoracoscopy and pleural biopsy are also techniques used to determine causes and complications of pleural effusions. This is most helpful in the incidence of malignant problems, such as mesothelioma, as well as in the case of tuberculosis or a trapped lung (National Lung Health, 2000).

Complications to a chest tube insertion for draining can arise to include bleeding, infection and subcutaneous emphysema (Coughlin, & Parchinsky, 2006). In addition the lack of appropriate follow up is an important component in limiting potential complications. Lab analysis and radiographic studies are important and it is vital the physician receive this critical data for review and help in treatment plans. Missed diagnosis due to lack of this critical information is also a potential for complications.

Assessment

Patient has decreased breath sounds with intermittent rapid breathing and cough. Chest tubes appear to be appropriately in place. There is dullness to percussion and decreased tactile fremitus. Shortness of breath and dyspnea are evident. Auscultation of the chest reveals tubular breath sounds and coarse crackles with rhonchus. There appears to be pleural rubs in addition.

Patient appears to be in good spirits although experiencing pain. Discussion held with the patient her diagnosis and expected route of recovery versus complications. Psychologically the patient is stable and no evidence of intervention warranted to date.

Current laboratory results reveal amylase 57, lipase 91, sodium 138, potassium 4, chloride 102, c02 29, BUN 12, creatinine 0.7, glucose 120, calcium 10.1, bilirubin 0.5, alkaline phosphatase 165, AST 21, ALT 26, WBC 8.4, hemoglobin 13.7, hematocrit 39.2, platelet count 315. Supine chest x-ray reveals a homogenous increase in density over the lower lung fields. This is accompanied by an enlarged heart shadow. CT of the chest reveals parenchymal disease with pleural thickening.

Nursing Diagnosis

Pleural effusion is the primary diagnosis for this patient. Decreased cardiac output related to altered contractility as evidence by dyspnea and cough.  There is ineffective airway clearance and ineffective breathing pattern. She is at risk for ineffective tissue perfusion: cardiopulmonary. There is risk for excess fluid volume related to excess intake of sodium and water: edema. The patient is at risk for injury related to the therapeutic puncture of the lung: pneumothorax. Activity intolerance is also evident in this patient. Risk for fluid volume deficit related to administration of diuretic medications.

Planning and Implementation

Ms. N.Z. will need continual vital sign monitoring and assessment of breath sounds bilaterally. Supplemental oxygen should be provided as necessary and per physician orders. Assess patient for respiratory changes. Auscultation of lungs to monitor for decreased breath sounds and pleural rub (Day, 2009). Monitor insertion site of chest tube.

Encourage the patient to cough and teach deep breathing technique for proper drainage and lung expansion. She will need pain assessment for management. Maintain tubing to be free of kinks and ensure connections are securely in place and taped for prevention of loosening. Assess drainage color in tubing and measure every eight hours; depending on patient clinical status. Continual proper documentation of drainage volume and color. Patient positioning and frequent repositioning, ambulation or chair setting as physician ordered (Coughlin, & Parchinsky, 2006).

Conclusion

Ms. N.Z. appears stable and compliant with treatment planning. She is cooperative and has excellent family support system in place. After discharge the patient will be scheduled for follow up visits with her physician for continued monitoring and assurance of continual healing and prevention of recurrence.

References

All Nurses (2008, January 8). Pleural effusion: help on nursing diagnosis. Retrieved from http://allnurses.com/nursing-student-assistance/pleural-effusion-help-272104.html

Coughlin, A.M., & Parchinsky, C. (2006). Go with the flow of chest tube therapy. Nursing 2006, 36(3). Retrieved from http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=633441

Day, Michael W “Caring for patients with pleural effusion”. Nursing. FindArticles.com. 21 Oct, 2009. http://findarticles.com/p/articles/mi_qa3689/is_199810/ai_n8825389/

Frontline Assessment of Common Pulmonary Presentations (2000). National Lung Health Education Program. Retrieved from http://www.nlhep.org/books/pul_Pre/pleural-effusion.html

Wong, C.L., Holroyd, J., & Straus, S.E. (2009). Does this patient have a pleural effusion? JAMA, 301(3). Retrieved from http://jama.ama-assn.org/cgi/content/abstract/301/3/309