Category: Nursing Care Plan

Introduction

The case study provided about Mr. Issler shows that he has been suffering from heart problems for some time. It is evident that he lacks proper family care back at home. He is currently under the care of his daughter-in-law who moved in with him a few months ago. The most appropriate nursing concept that is applicable in his case is Roy Adaptation Model. This theory holds that patients’ adaptation is based on the interaction with the environment (Roy, 2013). Choice, conscious awareness, and self-reflection all help in the creation of environmental integration. Mr. Issler must understand that the medical condition of his heart is very delicate, especially after the confirmation from the laboratory tests. He has to integrate with the social environment to find best ways of managing his complication.

Plan of Care for the Patient

Introduction

According to Kaur and Mahal (2013), people suffering from coronary diseases need proper plan of care because of the unpredictability of a possible heart attack. Mr. Issler has congestive heart failure (CHF) and a history of deep vein thrombosis (DVT). These are serious complication that may lead to heart attack at any moment, especially if the patient fails to maintain a given lifestyle. In this plan, the patient will play a central role in ensuring that he remains in good health, just as stated in the above theory. The deep vein thrombosis may cause blockade of blood in delicate body organs that may lead to serious medical problems if care is not taken as soon as possible. For this reason, it will be necessary for the patient to maintain regular exercise. Regular exercise will help burn extra calories in the body that may cause problems to the patient. It will also help to improve the health status of the heart (Judd, Sitzman, & Davis, 2010). The delicate nature of the patient’s heart- caused by congestive heart failure- demands that the exercises must be regulated by an expert. Mr. Issler will, therefore, need an instructor who will define the kind of exercises that he should embrace. This may include slight jogging or just walking for a given distance every morning before going to work.

The patient will also need to be disciplined when it comes to his food intake. Fitzpatrick and Kazer (2012) warn that individuals who have heart problems may face serious danger if they fail to adhere to a given diet at all times. All types of food with high calories should be avoided by this patient. This includes red meat and excess carbohydrates. Finally, Mr. Issler may need to resolve his relationship with his son given that he is the only family member who can be genuinely concerned about his health. Currently, the patient is staying with his daughter-in-law who moved in with him a month ago. She is no longer married to his son, a fact that means the family bond is already broken. Morally, he should not have moved in with her. His delicate heart condition may not permit him to stressful environments such as a fight with the son.

Family members also have a role to play in this care plan. Maintaining a healthy lifestyle does not rule out a possibility that the patient may experience heart attack at any moment. When this happens, family members should be close by to offer primary care and rush him to the nearest medical facility. The concerted effort may help in eliminating the dangers Mr. Issler may face.

Analysis of congruence of concept and theoretical statements

The concept environmental integration as defined in Roy Adaptation Model is congruent to the condition of the patient. This theoretical statement emphasizes on the role of the patient in the care plan. Mr. Issler’s condition has a lot to do with his lifestyle. No one can manage his way of life better than himself. That is why it is necessary to involve him in the plan as a primary caregiver to himself. Any other help that will come from nurses and family members will only be supplementary. Taking control of one’s health, according to DeNisco and Barker (2013), is the best way of fighting lifestyle-related health complication. It will mean that an individual will remain disciplined at all times, always avoiding anything that may be a threat to their health.

Current influences of research utilization in practice

The current research has massively influenced nursing practice in many ways. For instance, Carpenito (2011) recalls that in the past, patients suffering from health problems were advised to avoid exercise and any activity that is physically demanding. However, recent studies have proven that these patients should actually engage in physical activities as a way of strengthening their heart muscles. Advances made in the field of nursing and medicine has helped a lot in improving the kind of care that patients now get in medical institutions. Nursing practice is heavily informed by the findings of modern research. Roy Adaptation Model is one of the research findings that have redefined the field of nursing in this century.

References

Carpenito, L. (2011). Nursing diagnosis: Application to clinical practice. Philadelphia, Pa: Lippincott Williams & Wilkins.

DeNisco, S., & Barker, A. M. (2013). Advanced practice nursing: Evolving roles for the transformation of the profession. Burlington, Mass: Jones & Bartlett Learning.

Fitzpatrick, J., & Kazer, M. (2012). Encyclopedia of nursing research. New York: Springer Pub.

Judd, D. M., Sitzman, K., & Davis, M. (2010). A history of American nursing: Trends and eras. Sudbury, Mass: Jones and Bartlett Publishers.

Kaur, H., & Mahal, R. (2013). Development of Nursing Assessment Tool: An Application of Roy’s Adaptation Theory. International Journal of Nursing Education, 5(1), 60-64.

Roy, C. (2013). The Roy adaptation model. Upper Saddle River, NJ: Pearson Prentice Hall.

Subjective Data

Client Complaints: The patient reports coughing for two weeks; there is shortness of breath and a slight fever.

HPI: A dry night cough is observed for two weeks; the fever is observed for two days. The appetite is decreased. She is not able to breathe easily.

PMH: The patient refused hospitalization because of possible pneumonia and found emphysema three months ago. She was prescribed to use inhalers, antibiotics, and Tylenol (650 mg, 2 PO) when necessary. She had asthma when being a child. She had a hysterectomy. The female has an allergy to sulfa drugs.

Significant Family History: One of the patient’s sisters has osteoporosis, and the other sister has breast cancer.

Social/Personal History: The patient is retired; she is a widow for 20 years; her income is stable. She follows a healthy diet, but she does not exercise enough. The female smokes regularly.

Description of Client’s Support System: She communicates with grown-up daughters rarely, and she is not interested in community resources. A primary care provider visits her not often.

Behavioral or Nonverbal Messages: The patient feels depressed; her level of anxiety is high because she is afraid of having lung cancer or heart diseases. Depressive symptoms have worsened.

Client Awareness of Abilities, Disease Process, and Health Care Needs: The female has the limited knowledge regarding her pulmonary problems and the possible treatment.

Objective Data

Vital Signs including BMI: BP: 130/72 left arm; P: 100; R: 20; T: 101°F; BMI = 8.13.

Physical Assessment Findings: Decreased breath sounds in lungs, right lower lobe percussion – dull; the increased anterior-posterior diameter of the chest wall. No rales. Heart: RRR. No edema.

Lab Tests and Results: X-ray results indicate hyperinflation, an increased AP diameter. CBC – WBCs 15,000, left shift. SAO2: 98%. EKG – sinus rhythm is normal.

Client’s Support System: The contacts with the primary care provider are regular but limited in time; the socialization is also limited.

Client’s Locus of Control and Readiness to Learn: It is difficult to educate the patient because she is inclined to deny the necessary testing and treatment procedures.

ICD-10 Diagnoses/Client Problems

J439 Emphysema, unspecified;

J440 Chronic obstructive pulmonary disease (COPD) with acute lower respiratory infection;

J209 Acute bronchitis, unspecified;

F328 Other depressive episodes;

Z882 Allergy status to sulfonamides;

F419 Anxiety disorder, unspecified;

Z720 Tobacco use;

Z723 Lack of physical exercise;

Z8262 Family history of osteoporosis (Centers for Medicare and Medicaid Services, 2016);

Family history of breast cancer;

Personal history of asthma.

Advanced Practice Nursing Intervention Plan

Goal and Outcomes: The patient will cope with the infection; the gas exchange will be controlled; the patient will cope with depression and give up smoking; the patient will gain weight.

Patient Involvement: The patient will be educated regarding the necessity of additional diagnostics and the therapeutic care and management to prevent the worsening symptoms. The patient will control the weight at home and follow the medication therapy.

1. Diagnostic Tests: (1) laboratory testing to determine the infection causing acute bronchitis; (2) pulmonary function tests (PFTs); (3) CBC with differential; (4) screening for depression; (5) chest CT.
2. Medications: Continue taking Tylenol 650 mg, by mouth as needed; start taking antibiotics (not including sulfonamides) to address the determined infection and bronchodilators, once a day. Start taking antidepressants if the depression screening is positive.
3. Conservative treatments: The patient should focus on giving up smoking. The O₂ therapy and the use of inhalers are recommended. The female should weigh every day and control changes in a diary. The enhancement of nutrition and pulmonary rehabilitation are also recommended.
4. Education: The education plan should include the developed diet presented for the patient as a brochure to consult; the plan for the smoking cessation; and the exercise program to address the physical inactivity. The focus is on light aerobic activities and walking. Written and verbal instructions on taking medications and following exercises and the diet should be provided.
5. Collaboration and referrals: (1) Pulmonologist – to conduct necessary testing; (2) Nutritionist – to improve the diet; (3) Psychologist – to receive the counseling regarding depressive symptoms; (4) Community Services – to participate in smoking cessation programs.
6. Follow-up: in a week after taking antibiotics – to check the temperature and conduct the chest investigation; in three weeks – to evaluate the weight, as well as heart and respiratory rates; in a month – to check WBC and changes in SAO2.

Rationale: In terms of diagnostics, PFTs are most appropriate to monitor the progress of COPD and check the oxygen consumption. It is also necessary to monitor changes in SAO2 and PAO2 in order to control the possible development of the impaired gas exchange (Mascalchi, 2015). Controlling CBC and WBC is necessary to predict the further development of the lung infection and associated diseases, including acute bronchitis and pneumonia, because it is a risk factor for the elderly people (Clark, Medina, Batham, Curran, & Parmar, 2014). The screening for depression is required because the patient’s management of COPD depends on this factor, and the consultation with the psychologist is important to address the patient’s anxiety (Zockler, Rief, Stenzel, Kuhl, & Kenn, 2012).

The choice of medications is based on the necessity to help the patient cope with the infection, breathe easier, and overcome depressive symptoms. It is important for the patient to follow the nutritional plan because she suffers from the extreme thinness. It is possible to take nutritional supplements (Collins, Stratton, & Elia, 2014). The cooperation with the pulmonologist is necessary to monitor the development of COPD and the O₂ saturation.

References

Centers for Medicare and Medicaid Services. (2016). 2016 ICD-10-CM and GEMs. Web.

Clark, T. W., Medina, M. J., Batham, S., Curran, M. D., & Parmar, S. (2014). Adults hospitalised with acute respiratory illness rarely have detectable bacteria in the absence of COPD or pneumonia; viral infection predominates in a large prospective UK sample. Journal of Infection, 69(5), 507-515.

Collins, P. F., Stratton, R. J., & Elia, M. (2014). Nutritional support in chronic obstructive Pulmonary Disease (COPD) a randomised trial. Clinical Nutrition, 33(1), 65-74.

Mascalchi, M. (2015). Pulmonary function tests and computed tomography lung attenuation in chronic obstructive pulmonary disease. Journal of Thoracic Disease, 7(11), 1882-1889.

Zockler, N., Rief, W., Stenzel, N., Kuhl, K., & Kenn, K. (2012). Do illness beliefs predict depression and quality of life after pulmonary rehabilitation? European Respiratory Journal, 40(56), 1472-1489.

Introduction

A number of patient assessment tools have been developed for the assessment of older people focusing on the patient’s ability to maintain activities of daily living (Ware, 3-11). These instruments, however, lack a systematic assessment of patient preferences as an important part of successfully initiating patients in making necessary changes in health behavior to regain or maintain capabilities in independent functioning. A holistic perspective nursing adopted as its underlying philosophy the need to integrate patients’ values, beliefs, and goals into nursing care but patient problems have usually been identified from the perspective of health care providers and their assumptions about which problems are important, without verifying these assumptions with the recipient of care – the patient (Moore & Kramer, 163-168). Evidence showed that a successful clinical relationship is one where patient and caregiver arrive at a consensus concerning the problem, physiological processes, prognosis and optimal treatment (Felch, 12) and a negotiated approach to decisions about patient care has been encouraged. In this essay, I will try to demonstrate client assessment from a nursing point of view that includes evaluating body functioning according to the Lorensen’s Self-Care Capability Scale (LSCS) that includes eating, drinking, eliminating, sleeping, moving, bathing, and grooming. Following this, I shall develop a nursing care plan in a case study format. Assessment is the first stage in the nursing process, and in order to conduct it rationally, a nurse must competently collect data from many sources, then analyze and synthesize it, before using the obtained data to develop a healthcare plan followed by the final evaluation. Accurate judgments can then be made about the patient’s health status and the nursing intervention required (Lazerowich, 121-126). The selected patient will be discussed using a model/framework for assessment that is used in practice. Three main needs of the patient will be outlined in the post-operative period following surgery.

Chosen Patient

Ms. Anderson, a 75-year-old woman presents at her annual physical examination. Her medical history, physical examination, and test results are as follows. In order to gather data about Ms. Anderson, a data collection tool was used. The tool contained the assessment of bodily functions according to LSCS and addressed the need to maintain those functions (see appendix).

Health History

Health History has been smoking heavily for 25 years. Considers herself ill during the course of the last 15 years, when after retirement Ms. Anderson started working as a janitor, where she experienced unfavorable thermal regimens. During her janitor work often experienced an ailment and took sick leaves from work once or twice each year. She left the job in two years, however continued to experience ailment two times annually. The symptoms usually included a fever of 37.6-38.2^o C, coughing with a scanty amount of colorless sputum, accompanied by general weakness and dyspnea at rest. During ten years Ms. Anderson was diagnosed with an acute respiratory viral infection, or acute respiratory disease, and prescribed antibiotics such as erythromycin, which caused the significant improvement. The fever disappeared in 7-8 days. The amount of sputum slightly increased and the coughing faded away. The patient recovered on the 2^nd -3^rd week. Three years ago she went to a different doctor, who arrived at the diagnosis of chronic bronchitis. Within the last three years, the aggravations became more frequent (3-4 times per year). The latest aggravation happened 3 weeks ago when during another exacerbation of chronic bronchitis the overall well-being started to decline (this followed Ms. Anderson going outside on the 5^th day of chronic bronchitis exacerbation): gradual rise of body temperature (38.4^o C in 24 hours), slight Algor and hyperhidrosis, increase of the coughing, the onset of dyspnea.

In 24 hours following these symptoms, Ms. Anderson called the ambulance. At the time of admittance to the hospital, her fever was 39.0 ^o C. From the patient’s words during the last three winters, her smoker’s cough produced sputum on most days. She complains of fatigue, constant coughing, and shortness of breath at rest. She is limited in her activities of daily living but she states that she is not taking part in any sports. The patient appears to have no asthma, allergies, gastrointestinal, or cardiac symptoms. Her family history revealed that her mother died at the age of 70 from stroke and her father died at age 67 from lung cancer. Both were heavy smokers. One sister aged 42 has breathing difficulties and is taking adrenoceptor agonists (salbutamol). Ms. Anderson has undergone an appendectomy 25 years ago. At about the same time she was in the hospital for removing calculus in both kidneys, and an x-ray revealed a cyst in the left kidney. 20 years ago she has undergone nodular hysteromyoma surgery. Around 22 years ago the patient was diagnosed with primary hypertension, as well as ischaemic heart disease: stenocardia. In 1992 Ms. Anderson survived a cerebrovascular accident.

Physical examination

The general condition of the patient is satisfactory. The consciousness is lucid. The body constitution is normothermic, height – 153 cm, weight – 92 kg, posture is slouchy, limps when walking. The body temperature is 36.8^o C. Facial expression is calm. The skin color is pale, without cyanosis. The skin is dry turgor pressure is low. Mucosal membranes are pale. The nails are without any visible deformations. The subcutaneous fat is well developed, mostly on the abdominal, lumbar, and femoral regions. Insignificant pastousness in the lower leg regions. The main groups of lymphatic nodes are not enlarged during palpation. The muscles are of sufficient development, with low tonicity. Bones are without visible alterations. Joints demonstrate alterations in both radiocarpal, and the left popliteal joint, which is tender during palpation. The patient also complains of paroxysmal pain in the spinal cord. The thyroid gland does not palpate. The respiration is thoracic, symmetrical, and shallow, with 20 breaths per minute. The palpation revealed low elasticity of the thoracic cage. Pectoral fremitus is increased insignificantly. The auscultation of the lungs revealed adverse respiratory murmurs – small bubbling rales in the left axillary and scapular regions. Complains of constricting pains behind the sternum after physical exertion. The arterial pulse rate is 80 beats per minute. The abdomen is slightly enlarged due to fat deposits. The edge of the liver is algesic during palpation. The urogenital system and nervous system are without pathology. The vision acuity and locomotor reactions are lowered.

Test Results

The complete blood cell count revealed: Hemoglobin – 118 g/l (low), erythrocytes 4.4, globular value – 0.85 (low), leukocytes – 6.7/L, monocytes – 6%, eosinophiles – 5%, lymphocytes—26%, blood platelets – 180/L, ESR – 5 mm/h. The biochemical blood assay: total protein – 65g/l, alanine aminotransferase – 24 mmol/l, aspartate aminotransferase – 28 mmol/l, glucose – 5.2 mkmol/l. The urine test showed no traces of erythrocytes or urinary cylinders. The urinary level of leukocytes is 452 mln/l. The sputum test results are as follows: color – gray, type – mucosal, consistency – mucilaginous, eptithelium – small amounts, leukocytes – 25-30 within the visual field. The streptococci from the sputum demonstrated resistance to penicillin, ristomycin, chloramphenicol, and tetracycline. The x-ray of the pectoral region revealed emphysema with diffuse pneumosclerosis. The lung pattern is deformed, as there is lesser circuit hypertension. There are infiltrative alterations in the basal layer of the left lung. Both ventricles of the heart are enlarged equally. The sonographic examination revealed enlarged liver and induration of the kidneys with an insignificant amount of concrements (0.3-0.5 cm). The ECG showed the electrical axis of the heart rotated to the left, and slight hypertrophy of the left ventricle. The conductive function is adequate (P-Q=0.14sec., QRS=0.08 sec). PO2 = 50 mmHg.

Functional Assessment

Spirometry is compatible with mild obstruction and no significant reversibility. During physical exercise – explicit dyspnea.

Cognitive and mental health assessment

The patient’s consciousness is clear, she is well oriented in time and space, answers the questions adequately, but with delay, does not appear to be talkative. The papillary reaction to light is normal, although the visual acuity is lowered. The face is symmetrical, and there are no signs of meningeal symptoms.

Socio-environmental assessment

Ms. Anderson is retired and is currently residing with her sister. The living conditions are satisfactory.

Nursing Care Plan

Nursing Care Plan – based on the history of the current disease, namely that the onset occurred against the background of chronic bronchitis aggravation, it is rational to verify the diagnosis of chronic obstructive bronchitis (Royer, 42). The most informative are Ms. Anderson’s complaints which are indicative of this illness. The most significant assessment data are the results of functional external ventilation tests that indicate an obstructive alteration in the current patient. In such a manner, the chronic obstructive bronchitis diagnosis is based mainly on the history and complaints of the patient, as well as functional ventilation tests (Burke & Laramie, 43). The diagnosis of acute sinister bronchopneumonia of medium severity is based mainly on the patient’s complaints which include fever of 39.2 accompanied by chills, coughing, and heaviness in the left side of the chest, just below the scapula, improvement of the condition after antibiotic therapy. The examination findings, such as respiratory small bubbling rales in the left axillary and scapular regions also contribute to the above diagnosis. The laboratory finding that is evident of inflammation ESR below 20 mm/h. The infiltrative alterations of the left lung on the x-ray are also relevant. Summarizing the above data it is certain that Ms. Anderson has bronchopneumonia that has typical characteristics, such as slight symptoms of intoxication and inflammation (Murray, 18). The x-ray of the chest, as well as auscultation, helped determine the affected side. It is clear that the duration of the disease is of medium severity, as the patient is 75 years old, and has chronic disabling diseases in her medical background (arterial hypertension, chronic obstructive bronchitis).

The diagnosis of respiratory distress is arrived upon based on the patient’s complaints – dyspnea when going up the stairs, or walking for 200 meters, as well as on the external ventilation tests. Based on the above findings Ms. Anderson can be diagnosed with Chronic Obstructive Pulmonary Disease (COPD). When prescribing treatment it is important to note that the patient besides bronchopneumonia and chronic obstructive bronchitis is suffering from arterial hypertension and exertional angina (Shaw, Peterson & Mark, 141-148). It is essential that Ms. Anderson receives her treatment for bronchopneumonia as soon as possible, as in this case, it will be effective. This patient must be hospitalized, as she is over 65 years old, has severe accompanying conditions, and can not be provided with adequate care at home. From a nursing point of view, it is necessary for the patient to follow a strict bed regimen (Ebersole & Hess, 75). This means that her eating, drinking, and elimination needs must be rationally satisfied. The nurses must also take care of the patient’s hygiene. This includes frequent bathing and grooming. The bed regimen may be not as strict, once the signs of intoxication and fever go down. The patient’s general satisfactory condition means and that she moves actively means that there is no need for decubitus ulcer prevention. The treatment that she receives must include primarily penicillin-type antibiotics, for example, intramuscular injections of ampicillin twice a day (Ruben & Stout, 164). It is rational to prescribe combined antibiotic therapy, as there is accompanying pathology and immune deficiency. This additional treatment should include aminoglycosides, such as gentamicin that is injected intramuscularly twice a day.

The duration of the therapy shall depend on signs of improvement, a decrease in the body temperature, and level of intoxication. It is necessary to continue this treatment for five days after the condition improves. Expectorant drugs such as bromhexine are also required to drain the bronchial tree, especially the segmental bronchus in the affected locus. Immune modulators are needed to correct the immune status (Freeman, 64-94). In order to do this, the patient shall be administered ascorbic acid, thiamine, and tocopherol in form of intramuscular injections. A nursing care plan may also include physiotherapy that can be used to rehabilitate Ms. Anderson’s condition after the acute period has passed (Kemp, Brummel-Smith & Plowman, 9). The most effective physiotherapy would be bronchial spasmolytic inhalations. These can include such medications as beta-2 adrenal agonists. There is also a possibility of conducting exercise therapy that will increase tolerance to physical stress. Various coronarodilators can be used to prevent complications of ischemic heart disease and stenocardia. The expectancy of absolute recovery outcome for a patient that had acute bronchopneumonia and chronic obstructive bronchitis is negative (Hart, Laden, Schenker & Garshick, 1013). This is due to the lengthy progressive duration of chronic bronchitis, old age, and accompanying pathology of the heart. The most effective healthcare strategy, in this case, is decreasing the development of major chronic disorders.

Educational Nursing Care Plan

Nursing Diagnosis

The patient/client has a problem/potential problem in his/her need for adequate breathing because she is not able to perform the physical exercise without showing signs of explicit dyspnea.

Expected Outcome

The best possible situation that this particular patient/client can achieve in three days is that she will be able to walk without experiencing severe shortness of breath.

Evaluative Criteria

I will know if the expected outcome is achieved if I can observe Mrs. Anderson walking for 200 meters without experiencing dyspnea.

Planned Interventions

The most appropriate way for the patient/client to achieve their Expected Outcome is for the patient/client and me to ensure that Mrs. Anderson has adequate oxygen supply to her lungs.

Rationales

The reasons I have chosen these particular interventions are because a higher supply of oxygen will cause better oxygenation of hemoglobin in her blood and shall prevent hypoxemia and improve the quality of life, by enabling the patient to perform activities of everyday living. This rationale will also prevent the possible complications of COPD, such as cor pulmonale or pulmonary hypertension. In order to provide better oxygenation of hemoglobin, long-term oxygen therapy (LTOT) must be used as the most effective rationale. There are many forms of administering LTOT, however, in this case, a reservoir, nasal cannula should be used. It will collect the expired gasses and enable the patient to rebreathing the air from the oxygen delivery system during the next breath. The nasal cannula is equipped with a sensor of oxygen pressure in the nose and shall deliver oxygen only during inhalation.

Evaluation

Using the evaluative criteria, what I now observe is an increase in exercise tolerance and improvement of mental functioning, as the patient is able to walk a distance of 200 meters without feeling dyspnea, and also appears to be in a more lively mood and more talkative.

This corresponds with what I anticipated therefore I will advise the patient to continue using LTOT in home conditions after being signed out from the hospital.

Conclusion

In assessing Ms. Anderson, I found that the models discussed above were practical to gain insight into the care and treatment needed. I established that in order to properly provide an effective nursing plan, it is necessary to focus on the patient’s needs, her interpretation or understanding, as well as require or might want to do and can do in order for her to improve her own health.

References

Burke, M. M., & Laramie, J. A. (2000). Primary Care of the Older Adult: A Multidisciplinary Approach. St. Louis, MO: Mosby (p. 43).

Ebersole, P., & Hess, P. (1998). Toward Healthy Aging: Human Needs and Nursing Response. St. Louis, MO: Mosby (p. 75).

Felch, W. C. (1996). The Secret(s) of Good Patient Care: Thoughts on Medicine in the 21st Century. Westport, CT: Praeger Publishers (p. 12).

Freeman, L. W. (2001). 3 Psychoneuroimmunology and Conditioning of Immune Function. In Mosby’s Complementary Alternative Medicine: A Research-Based Approach (pp. 66-94). St. Louis, MO: Mosby.

Hart, J. E., Laden, F., Schenker, M. B., & Garshick, E. (2006). Chronic Obstructive Pulmonary Disease Mortality in Diesel-Exposed Railroad Workers. Environmental Health Perspectives, 114(7), 1013+.

Kemp, B., Brummel-Smith, K., & Plowman, V. J. (1989). Geriatric Rehab Program Focuses on Research, Training and Service. The Journal of Rehabilitation, 55(4), 9+.

Lazerowich, V. (1995). Development of a Patient Classification System For a Home-Based Hospice Program. Journal of Community Health Nursing, 12(2), 121-126.

Moore S.M. & Kramer F.M. (1996) A comparison of women’s and men’s preferences for cardiac rehabilitation program features. Journal of Cardio-pulmonary Rehabilitation 16, 163–168.

(1992). Measuring Functioning and Well-Being: The Medical Outcomes Study Approach (A. L. Stewart & J. E. Ware, Ed.). Durham, NC: Duke University Press (p. 41).

Murray, J. F. (2000). Intensive Care: A Doctor’s Journal. Berkeley, CA: University of California Press (p. 18).

Orem D.E. (1995) Nursing: Concepts of practice. Mosby, St Louis. Palmer R.M., Landefeld C.S., Kresevic D. & Kowal J. (1994) A Medical Unit for the acute care of older people. Journal of the American Geriatrics Society 42, 545–552.

Royer, A. (1998). Life with Chronic Illness: Social and Psychological Dimensions. Westport, CT: Praeger Publishers (p. 42).

Ruben, D. H. & Stout, C. E. (Eds.). (1993). Transitions: Handbook of Managed Care for Inpatient to Outpatient Treatment. Westport, CT: Praeger Publishers (p. 164).

Shaw, L. J., Peterson, E. D., & Mark, D. B. (2002). Chapter 7 Clinical Recognition: Risk Assessment Screening. In Heart Disease in Women (pp. 141-148). New York: Churchill Livingstone.

Ware, J. E. (1992). 1. Measures for A New Era of Health Assessment. In Measuring Functioning and Well-Being: The Medical Outcomes Study Approach, Stewart, A. L. & Ware, J. E. (Eds.) (pp. 3-11). Durham, NC: Duke University Press.

Ziguras, C. (2003). Self-Care: Embodiment, Personal Autonomy, and the Shaping of Health Consciousness. New York: Routledge (p. 41).

Appendix

The Model

LSCS (Lorensen’s Self-Care Capability Scale) was chosen in order to systematically incorporate patients’ preferences in the assessment of older people comprising aspects not found in other instruments. Assessment tools for this patient population include assessing body functioning, such as eating, drinking, eliminating, sleeping, moving, bathing, grooming, Orem’s self-care model as a conceptual framework which is widely known and accepted by nurses.

The model defines three categories of self-care requisites necessary for performing self-care in maintaining life, health and well-being (Orem, 1995) that address the need to maintain bodily functions, such as the need for air, water, food, elimination, rest, solitude, social interaction and prevention of hazards, developmental and health deviation self-care requisites, developmental and cognitive capabilities. These are a prerequisite

to learning new self-care strategies, skills or behaviours (Ziguras, 41) such as the ability to seek appropriate medical assistance, carrying out medically prescribed measures effectively, or altering one’s life-style to promote personal development while living with the effect of pathology and medical measures (Orem, 545-552).

The Royal College of Physicians and the British Geriatrics Society highlighted the need for functional assessment of elderly people as part of routine clinical practice. It recommends the regular use of standardized assessment scales in activities of daily living, communication, cognitive function and memory, depression and quality of life. Regular se of these measures may be useful in planning, clinical care, provision of support services, screening, outcome assessment, clinical audit and casemix.

Abstract

Jose is sixty-three years old, and he is suffering from diabetic neuropathy. According to the chief concerns, his diabetic neuropathy is classified as peripheral. Jose presents with severe pain in toes, feet, and legs. The major cause of pain is nerve damage in the legs which is evident through burning sensation, extreme sensitivity, and feet numbness. The healthcare provider has the mandate of maintaining the blood glucose levels close to the normal range in order to protect nerve damage throughout the body. Major diagnosis involves physical examination of blood pressure, temperature, heart rate, reflexes, and sensitivity. Medications that Jose received are pain relievers such as gabapentin, acetaminophen, and tramadol. Foot care involves quitting smoking and increased physical exercises.

Scenario

Jose is 63 years old, born in Portugal, and lives in Canada. Jose main health issues are leg pains, touch sensitivity, and feet numbness. History of illness shows that Jose had been diagnosed with Type II diabetes mellitus and coronary artery disease. The patient has a sedentary lifestyle and uses tobacco.

Nursing Diagnosis

Nursing diagnosis involves pain management in feet, obesity, coronary artery disease, and peripheral vascular disease. According to Perry and Potter (2009), frequent tests on blood glucose, urinalysis, and kidney biopsy are essential for early diagnosis of the diabetic neuropathy. Extreme sensitivity that Jose is experiencing is called hypersensitivity, and it occurs due to damage of nerve fibers. Jose is suffering from peripheral neuropathy. Peripheral neuropathy is caused by nerves damage that directly affects the toes, legs, arms, hands, and feet. Calf muscle pain is due to stretching of the calf muscle beyond the tension limit (Ackley & Ladwig, 2013).

Subjective and Objective Data

Subjective date involves examination of subjective symptoms such as nocturnal pain in the legs, nerve conduction on the lower limbs, and knee jack reflex effects. Objective data involve records of clinical evaluation such as parameters of good diabetic control. Some of the parameters of good diabetic control are daily monitoring of blood glucose, daily urine tests for glucose, and heart monitoring. Heart monitoring involves recording changes in the heart electric activity (Perry & Potter, 2009).

Nursing Outcome

Healthcare provider identifies that Jose has normal blood pressure, regular pulse rate and a body temperature of 37⁰C. The patient has complete loss of sensation in feet and is allergic to morphine sulfate. Ackley and Ladwig (2013) argue that, the reduction in tobacco intake will improve the foot care management. Physical exercises are essential for management of pain and increases nerve conduction.

Nursing Intervention

The name and age of the patient are correctly addressed for easy identification and follow-up. According to Cross and Rimmer (2002), close monitoring of vital signs of peripheral neuropathy is essential in order to provide baseline of correct medication. The patient gets administered with acetaminophens, gabapentin, and amitriptyline to help in relieving diabetic nerve pain. After careful assessment, Jose should withdraw amitriptyline because he shows no signs of depression. There is a likelihood of the increase in dosage of gabapentin and acetaminophen to manage the increasing rate of pain.

Evaluation

Jose’s pain is mostly in the feet due to muscle weakening and his sedentary lifestyle after retiring from his factory duties. Additionally, some of the damaged nerves damage may be relating essential information to the feet. The major symptoms of peripheral neuropathy are severe pain in foot, circulation problem that result to feet numbness and reduced knee jack reflexes (Cross & Rimmer, 2002). Possible approached in management of Jose’s condition are physical therapy, massage, gabapentin, and tramadol medication.

References

Ackley, B. J., & Ladwig, G. B. (2013). Nursing diagnosis handbook: an evidence-based guide to planning care. Missouri, MO: Elsevier Health Sciences.

Cross, S., & Rimmer, M. (Eds.). (2002). Nurse practitioner manual of clinical skills. Philadelphia, PA: Baillière Tindall.

Perry, A. G., & Potter, P. A. (2009). Clinical nursing skills and techniques. Missouri, MO: Mosby Elsevier.

Overview with cultural considerations

My patient is a 30-year old white American, who was hospitalized with complaints about sharp and acute pain in his neck and shoulders. The patient is a Christian who, however, does not attribute much attention to religion in his life. The patient has a family, and his wife and 7-year old daughter are rather supportive to him. The patient is a highly open person using the eye-contact and touch in his communicational acts.

The urgent medical assessment and testing proved that the patient had a hiatal hernia and required an urgent laparoscopic gastric bypass surgery to be carried out. After this, the patient went through a set of tests to examine his blood, pulse, blood pressure, and urine. The results of the preliminary tests manifested the patient’s readiness for the surgery and the possibility of using general anesthesia.

So, the patient was prepared for the surgery and brought to the surgery room. The very laparoscopy started 5 minutes later when the general anesthesia started working. Four minor incisions were made in the right part of the patient’s abdomen and the hiatal hernia repair was carried out. No complications were observed before, during, or after the surgery. The patient recovered from the general anesthesia rather early, and the PACU score of the patient was 2, using the gradation in which late recovery is 0, intermediate recovery is 1, and early recovery is 2.

After the surgery, the patient was placed in an ordinary ward because he coped with all general anesthesia effects well, and no need was observed to place the patient into the reanimation ward. The drainage sponge was placed in one of the stitches left after the laparoscopy to prevent the remaining blood and ichor from accumulating in the wound. Daily bandaging was carried out for the patient, who started walking the next day after the surgery. Now, the patient is on a non-irritating diet that limits his vegetarian preferences to neutral drinks and food. The nursing care plan is developed on the basis of nursing diagnostics to present the patient with the highest care standards (Muller-Staub, et al., 2008, p. 293).

Functional health pattern assessment

General appearance

My patient is in his bed now. His conditions are rather good, as he tried to sit in the bed, walks to the bathroom with the help of a nurse, and starts eating the simplest products his diet allows him to.

Reason for hospitalization

My patient was admitted xx/xx/010 reporting the long-lasting sharp pain in his chest. According to his complaints, the pain had been lasting for 15 minutes before he was placed in the hospital, and this was not the first case of such a pain fit (Smeltzer and Bare, 2009, p. 692).

Past medical history

The patient has a past medical history of angina and sharp and continuous pain in his neck and shoulders.

Health perception

The patient was taken to the hospital and underwent the laparoscopic gastric bypass as soon as the testing procedures confirmed his health conditions to be acceptable for such a procedure.

Nutrition/Metabolic pattern

The patient is now on a non-irritating diet, drinking fluids containing no acids and eating only neutral products.

Elimination pattern

The elimination patterns of my patient are all in order. His bowel and bladder control functions are at the proper levels.

Exercise pattern

The patient displays normal levels of activity. He does physical exercises to maintain the tonus of his muscles and avoid complications.

Sleep/Rest pattern

The sleeping and rest patterns are displayed by the patient care at the proper level. The patient can fall asleep during bedtime without taking any medications.

Cognitive pattern

My patient is alert, he recognizes people and things that surround him, can remember his past and can project his future.

Self-perception pattern

The patient is a 30-year old man, who perceives himself adequately and realizes his position in the objective reality. The patient can also properly formulate his needs and wishes.

Role/Relation pattern

The patient has a family, i. e. a wife and a 7-year old daughter. They are very supportive and help him get through the hardships of the post-surgery period. As well, the patient’s parents often visit him to express their love and support. Finally, the patient has many friends, who also help him recover from the surgery and return to his active daily life.

Sexual/Reproductive pattern

As stated above, the patient is married and has a 7-year old daughter. As he is a father, he values his family even more and is committed to recovering for the sake of his daughter.

Coping pattern

The patient displays no signs of stress or any other psychological issues, which evidences that his pattern of coping with the post-surgery recovery is rather strong.

Value/Belief pattern

According to the patient’s words, he is a Christan but is not used to attending church on the regular basis. Moreover, the patient displays deeply philosophical beliefs, which are conditioned by his committed interest in the subject.

Respiratory

The patient experiences slight respiratory difficulties, i. e. a partially ineffective breathing pattern, caused by the still observed effects of the laparoscopic surgery. However, the general characteristics of the patient’s respiratory functioning are positive. His respiratory rate fluctuates between 18 and 20 breathing per minute.

Cardiovascular

The cardiovascular conditions of the patient are proper. The patient’s SE blood pressure is 120/80, while pulse rate is at the stable level of 93. Accordingly, the patient takes no medications facilitating the functioning of the cardiovascular system, but still, he is under the permanent control of a cardiologist, which is the measure to diagnose and eliminate any problem if it emerges.

Neurological

The neurological conditions of the patient are stable and there is no need for special treatment thereof. The patient realizes that the situation he is in now is rather problematic, but the successful laparoscopy is sure to make his post-surgery recovery fast and without any complications.

Gastro-intestinal

The patient underwent laparoscopic gastric bypass and hiatal hernia repair. The current condition of the patient is stable. The drain sponge is placed into a loose stitch so that the remains of blood and ichor from the wound could be eliminated from the organism. The patient takes ketorolac intravenously twice a day to cope with the post-surgery pain (Aschenbrenner, 2008, p. 416). No need for additional medications to be taken is observed.

Genito-urinary

The genitor-urinary function of the patient’s organism is at the proper level of performance. The patient is continent with his bladder.

Musculoskeletal

The musculoskeletal system of the patient is functioning properly. On the whole, the musculoskeletal activities of the patient are voluntary and proper. No muscle strains and/or other problems can be noticed.

Integumentary

The patient’s skin is majorly intact and displays no obvious signs of damages or infections. The only places where the skin is damaged are laparoscopic stitches, around which slight red spots can be observed.

Care plan

Conclusion

So, my patient is a 30-year old American who has a family, recognizes the right of all people to be equal and to live properly. This patient has undergone laparoscopic gastric bypass surgery and hiatal hernia repair. Before the hospitalization, he experienced regular fits of sharp pain, which evidenced that he had a hiata al hernia. The surgery has been carried out successfully, and now my patient is in the stage of recovery. Thabove-presenteded care plan reflects the basic interventions I carry out to solve two major problems of my patient, i. e. partially ineffective breathing pattern and post-surgical pain (Muller-Staub, et al., 2008, p. 294). So, to achieve the goal of overcoming these problems, I plan to use both medications and breathing improvement techniques after prior analysis of both issues from a professional point of view.

Self-critique of the plan

The self-critique of the presented care plan for my patient allows making rather high assessments of the plan components. First, the RCC Evaluation Guidelines require any nursing care plan to include five major columns to reflect the nursing diagnosis, desired outcomes, nursing interventions, rationale for the latter, and evaluation of the effectiveness of goal achievement (RCC, 2010). The care plan I developed for my patient obviously has all these obligatory elements. Further on, the nursing diagnosis column should identify the patient’s state from the nursing viewpoint, and my care plan complies with this requirement as well (RCC, 2010). Desired outcomes are measurable and specific as the RCC standards require, while the list of nursing interventions always starts with hearing the client out and analyzing his problem. Further on, every nursing intervention is assessed and has its rationale presented, while the overall goal evaluation is presented in the context of achieving/not achieving the major goal of the client. Accordingly, the presented care plan conforms to all RCC requirements for nursing care plans.

References

Aschenbrenner, D. (2008). Drug Therapy in Nursing. Philadelphia: Lippincott Williams & Wilkins.

Muller-Staub, M. et al. (2008). Implementing nursing diagnostics effectively: cluster randomized trial. Journal of Advanced Nursing 63(3), 291–301.

RCC. (2010). Practical Nursing Program. Web.

Smeltzer, S. and Bare, B. (2009). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.

Introduction

Cholelithiasis occurs when gall stones obstruct the cystic duct resulting in discomfort (Tanya & Sara, 2011). Its prevalence is associated with increased consumption of high-fat meals. Cholecystitis on the other hand refers to gall bladder inflammation which results in the development of gall stones (Tanya & Sara, 2011). Generally, the two conditions are associated. Often an operation known as cholecystectomy is performed to reverse the condition.

Cholecystectomy involves excising of the gall bladder from the posterior liver wall and ligation of the cystic duct, vein as well as and artery. Usually, the performing surgeon approaches the gall bladder via the right upper paramedian or in some instances via the upper midline incision if appropriate.

In instances where there is a suspected presence of stones in the common duct, the cholangiographic operation may be undertaken. In instances where pathologic actions have dilated the common duct, the performing surgeon may further dilate the duct to facilitate the removal of the stones. A thin instrument is passed into the duct to collect the stones.

The stones are collected either as a whole piece or after being crushed into pieces as deemed appropriate. Usually, after exploration of the common duct, a T-tube is inserted by the surgeon to ensure that there is an adequate bile drainage mechanism during the healing process (Ibrahim et al., 2006). The tube also avails a route for post-operative cholangiography when such is necessary.

Often when laparoscopic cholecystectomy fails to provide for stone retrieval, traditional open cholecystectomy is applied. The same is also undertaken when a patient’s physique does not provide room for gall bladder access (Tanya & Sara, 2011). This is common with obese clients (Guerriero, 2008).

Adults with small frames also present problems in gall bladder accessibility and hence the need for conventional open cholecystectomy. Mostly this procedure is performed through laparoscopic incisions using a laser (Tacchino, Greco, & Matera, 2010; Tian et al., 2009). Most patients, however, prefer the conventional open cholecystectomy due to its acute symptomatology and avoidance of future stone presence recurrence.

Care setting

The care setting for after cholecystectomy operation is normally planned on a short-term basis. However, when complications arise including emphysema, gangrene, or perforation, in-patient stay may be appropriately indicated. Among the concern areas on admission include cholecystitis with cholelithiasis, pancreatitis, peritonitis, psychological care perspective, and possible surgical intervention (Tajima & Katagiri, 2009). Discharge planning is also necessary whereby several concerns are dressed including possible assistance with wounds and other homemaker tasks.

The nursing priorities will however include;

• Respiratory functionality enhancement
• Complications prevention
• Information dissemination about the condition including procedures, prognosis, and treatment necessities.

Discharge goals

Nursing care will focus on achieving specific goals t the time of discharging the patient. These will include;

• Adequate ventilation/oxygenation to meet the patient’s needs/requirements
• Minimizing/preventing possible complications (Pardo-Mindan et al., 2008).
• Sufficient information available on the disease process, surgical procedures, prognosis, and the adopted therapeutic regime (Syrakos, 2007).
• After discharge care plan.

Nursing Diagnosis

Various diagnoses are evaluated to establish the best possible approach in the patient’s treatment for the mentioned condition (Lukovich, Vanca, & Gero, 2009). Possible diagnoses for this case are discussed below and justification provided.

Nursing Diagnosis 1: Pain, Acute

Pain is related to biologically injuring agents like obstruction in the duct, inflammations, and tissue ischemia/neurosis. It is evidenced by patient reporting of pain, biliary colic, facial pain mask, as well as autonomic responses like change in blood pressure and pulse (Joris et al., 2007). The desired outcomes in pain management include patient reports of pain relief and demonstration of relaxation position as evidenced by patient’s activities.

Actions/Interventions

Managing pain takes either an independent or collaborative form. Independent pain management begins with observing and documenting the location of the pain. Pain is ranked based on the severity on a scale of 0-10 (Joris et al., 2007). The character of pain is also documented, for instance, if it is steady, intermittent, or colicky. After administration of pain killers, the patient is observed for responses and a report generated on the same. Additionally, the patient is encouraged to have bed rest and assume a comfortable position (Joris et al., 2007). The temperature of the environment is also regulated.

Rationale

Assessment and ranking of pain help in differentiation of the causes of pain and hence avail relevant information on progressions of disease, possible complication, and effectiveness of other measures of intervention put in place. Severe pain, for instance, indicates the development of further complications (Joris et al., 2007). Bed rest in low-Fowler’s position decreases intra-abdominal pressure. However, a patient is always let to assume the position with the least pain. Control the environmental conditions helps in the reduction of itchiness and skin dryness. Further, it limits dermal discomfort experienced by the patient.

Other than these independent pain management measures, collaborative measures include maintenance of status and insertion/maintenance of NG suction. Additionally, pain management drugs are administered as indicated. Such drugs include Anticholinergics like atropine and propantheline (Pro-Banthı-one) as well as sedatives like Phenobarbital. Narcotics are also administered including meperidine hydrochloride (Demerol) and morphine sulfate. Other drugs include Smooth muscle relaxants, for instance, papaverine (Pavabid) and amyl nitrite. Antibiotics are also administered.

Rationale

While anti-biotic are meant to eliminate infections and hence inflammation, most of the mentioned drugs are meant to directly relieve the patient from pain.

Nursing Diagnosis 2: Breathing pattern

This is often associated with pain, muscular impairment, reduced levels of energy, and the presence of fatigue (Vagenas et al., 2006). It is evidenced by changes in respiratory depth, lowered vital capacity as well as holding breath amounting to reluctance to cough (Tajima & Katagiri, 2009).

The desired outcomes will aim to establish an effective pattern of breathing on the patient. The patients will be monitored to avoid any signs of respiratory complications which may compromise his/her health.

Actions/interventions

These will include measures put in place to assess the patient’s health changes throughout admission. They include;

Respiratory monitoring

This may be done either independently or collaboratively as appropriate. Independent respiratory monitoring involves the following;

Monitoring and evaluating the rate and depth of respiration

Rationale:

Shallow breathing levels, respirations accompanied with splinting and holding of breathing often cause hypoventilation to require constant evaluation and monitoring to keep the patients breathing in check (Andrew, 2009).

Auscultate breath sounds

Rationale:

Possible atelectasis is suggested by areas with reduced/absence of breath sounds (Andrew, 2009). Adventitious sounds on the other hand suggest possible congestions.

Assisting patients in turning, as well as coughing and periodical deep breathing. Patients are also shown how to splint incision and given instructions on how to develop effective breathing patterns

Rationale:

These processes assist the ventilation of various lung segments and also improve mobilization alongside expectoration secretions.

Bead head elevation and maintenance of low Fowler position. When coughing or ambulating, the patient’s abdomen is provided with support

The measures facilitate the expansion of the lungs. Splinting provides for incisional support and in turn reduces tension exhibited by muscles (Pardo-Mindan et al., 2008). This promotes cooperation with the therapeutic regime being administered.

Collaborative measures in monitoring respiratory activities include;

Availing of assistive apparatus e.g. the incentive spirometer

Rationale:

It assists in the optimization of expansion of the lungs and hence offers a solution for atelectasis.

Analgesics are administered before availing of treatments for breathing as well as therapy sessions

Rationale:

This process enhances patient coughing capability as well as deep breathing.

Nursing diagnosis 3: Fluid volume, risk of deficiency

Possible associated risk factors, in this case, include losses resulting from NG aspiration, vomiting, restricted medical intake, and changed coagulation like declined prothrombin, reduced coagulation duration (Andrew, 2009).

On basis of the diagnosis, it is desired that the patient display sufficient fluid balance, the mucus membrane should be moist, skin turgor and urine output should be normal (Hong &, You, 2009).

Actions/intervention measures

Independent measures in this case are also classified as either independent or collaborative. Independent measures include the following;

Monitoring of I/0, including NG tube drainage, T-tube, and wound conditions. The patient is also weighed periodically to monitor changes

Rationale:

Information regarding replacement needs and organ capability are availed. The initial output of bile drainage should lie approximately between 200ml and 500ml (Candela, 2007). This is output through the T-tube. However, this value is expected to gradually reduce (Andrew, 2009). Large bile amounts indicate the presence of unresolved obstruction issues or biliary fistula.

Vital signs monitoring like membrane condition, peripheral pulse values, and capillary refill are necessary.

Rationale:

They act as indicators of circulation volume inadequacies.

Observation of bleeding signs

Rationale:

It enhances prothrombin reduction and prolongs coagulation duration in instances where bile flow is obstructed resulting in increased vulnerability to bleeding risks (Zhi et al., 2007).

Injections are administered using small gauge syringes and after venipuncture, the pressure applied takes a longer duration than it often does

Rationale:

This facilitates reduced trauma as well as bleeding/hematoma risks.

Patients are made to use cotton swabs and mouthwash in place of conventional brushing using toothpaste

Rationale:

This brings about a decline in gum bleeding.

Collaborative measures include the following;

Laboratory investigations monitor including Hb/Hct, electrolytes, prothrombin level/clotting time evaluation.

Rationale:

Offer relevant information on circulation volume flows, body electrolyte balance, and clotting factors adequacy.

Administration of IV fluids as well as blood products

Rationale:

This assists in the maintenance of sufficient circulation volume and assists in the replacement of clotting factors. The electrolytes aid in the correction of body imbalances de to excessive gastric and wound losses (Jacques et al., 2007). Vitamin K assists in the replacement of factors that facilitate the clotting process.

Nursing diagnosis 4: Skin/Tissue integrity and impairment

These are related to chemical substances e.g. bile, secretions stasis, altered state of nutrition as well as metabolic state and body structure invasion as a result of T-tubes insertion. It is evidenced by skin/subcutaneous tissue disruption (Jacques et al., 2007). The desirable nursing outcomes include healing of the wound without complications, demonstration of behaviors that enhance healing and also bar skin from breaking down.

Actions/interventions

Independent interventions include:

Observation of the color and another characteristic of drainage

Rationale:

During the initial stages, drainage contains bloodstains. This is expected to change to greenish-brown within a few hours.

Frequent changing of wound dressing and cleaning of the same using soap and water. Sterile petroleum jelly is applied to the wound.

Rationale:

These measures are useful in keeping the skin hygienically clean and hence protect it from excoriation.

Application of Montgomery straps

Rationale:

This measure facilitates regular dressing alterations and hence reduced the possibility of skin trauma (Tan et al., 2006).

Other independent intervention measures include the usage of disposable ostomy bags, placement in low fowler position, monitoring of the puncture sites, and checking of the T-tube and incisional drains to ensure continuous free flow (Jacques et al., 2007; Ji, 2006). Additionally, the T-tube is maintained in a closed circulation.

While ostomy appliances assist in the collection of large volumes of drainage for more accurate analysis, fowler’s position is adopted to facilitate bile drainage without complication. Areas of bleeding also need constant monitoring to avoid the possibility of unwanted bleeding (Jacques et al., 2007). Constant checking of the T-tube ensures that it remains in the duct to collect the stones being removed from the system (Witzke & Gagliardi, 2007).

Proper position of the aforementioned ensures that no unwanted substances accumulate in the operative area (Miguel, Frits, & Alexander, 2009). Additionally, maintaining the T-tube in closed systems of collection lowers contamination risk in addition to preventing cases of skin irritation (Ros & Carlsson, 2009).

Collaborative measures in wound care on the other hand include administration of antibiotics, clamping of the T-tube per schedule, regular surgical intervention measures, and monitoring of laboratory evaluations. Antibiotics are necessary for the treatment of cases of possible infection (Jacques et al., 2007).

Clamping of T-tube on the other hand allows testing of the common bile duct patency before removal of the tube (Tanya & Sara, 2011). A necessity may arise for drainage of blocked ducts or fistulectomy as a measure for treating abscess and mending of fistula. Laboratory results help detect cases of leukocytosis which show inflammatory processes for instance formation of abscess and pancreatitis development.

Nursing Diagnosis 5: Knowledge deficiency about the condition, prognosis, treatment, individual care, and needs after discharge

This is mainly a factor of lack of exposure, misinterpretation of information, lack of knowledge about possible sources of information, or sheer ignorance. It is evidenced by plenty of questions, misinterpretation of information, inaccurate following of instructions, and mythical beliefs infestation (Tanya & Sara, 2011; (Terlecka & Majewski, 2009).

The desired outcomes about this diagnosis include verbalization of patient understanding of the disease processes and potential complications among others. Additionally, the patient is expected to verbalize understanding of the therapeutic conditions and requirements (Tanya & Sara, 2011). The nurses need to perform a stepwise demonstration of procedures and explain to the patients the essence of each step. Patients should also be initiated into the changes that the condition brings along about lifestyle.

Actions/interventions

Information is a critical part of patients’ helping process. Without proper and adequate information, patients may find themselves being re-admitted for cases that could have been avoided. Teaching patients about the disease factors takes various forms (Malini et al., 2008). Firstly, the patients are taken through a review of the surgical process, procedure, and prognosis (Baraza, 2007). Based on this, patients can make informed decisions about their condition.

Additionally, the patient is taken through a demonstration process on incision/dressings as well as drains care and management. Through this, patient independence is enhanced and the risk of exposure to complications is further lowered. The nursing practitioners also recommend to the patients, periodic T-tube collection bag drainage and recoding of the corresponding output for purpose of medical evaluation (Malini et al., 2008; Ibrahim et al., 2008).

This eliminates the risk of reflux, strain, on the tube/appliance seal. Additionally, it avails information on the resolution of ductal edema and appropriate removal duration.

Other than the aforementioned indicatives, much emphasis is placed on diet considerations and more specifically low-fat diets, small meal intakes, and gradual re-introduction of various types of foods with time. This is to eliminate possible discomforts often resulting from improper fats digestions (Litwin & Cahan, 2010). The use of medication is also discussed with patients e.g. use of florantyrone and dehychloric acid among others (Hodgett et al., 2009).

This helps the patients understand the medication process including oral bile replacement which facilitates absorption of fats into the body system. Additionally, patients are informed of the risk of using alcoholic beverages during the healing period and this minimizes the risk of pancreatic involvement in the process (Litwin & Cahan, 2010; Ghazal et al., 2009). Patients are also informed of some occurrences which may surprise them, for instance, loose stools.

This psychological prepares the patients. Additionally, patients are advised to note and avoid foodstuffs that aggravate their conditions to avoid conditions of discomfort. Additionally, the patients are informed about conditions that may necessitate informing of a healthcare worker to avoid condition deterioration (Tanya & Sara, 2011).

Activity limitations are reviewed to provide the patients with limits within which he/they may engage themselves without putting themselves at risk of injury. Generally, information dissemination allows patients to fully understand what the disease entails and what is expected of them if the conditions are to be controlled and their health perfectly regained.

Conclusion

In conclusion, it is important to mention that each of the possible diagnoses must be accompanied by relevant evidence of existence. This is only possible if relevant tests, observations, and evaluations are constantly conducted on the patient. Results from these diagnoses provide the basis upon which decisions regarding the future medical approach of the patient are directed.

The approach borrows a lot from the concept of evidence-practice where every diagnosis is to be based on factual information about the patient. Patient medical history is fundamental to this approach as its dictates the viability of a given diagnosis or not. It is important to note that all measures put priority on the patient well being. Information emerges as a fundamental aspect of diagnosis which determines whether or not a patient’s condition improves upon discharge from the hospital.

References

Andrew, A. G. (2009).Totally Transumbilical Laparoscopic Cholecystectomy. Journal of Gastrointestinal Surgery, 13(3), pp. 533-534.

Baraza, R. (2007). Laparoscopic cholecystectomy at the Nairobi Hospital: a personal experience with 42 cases. East Afr Med J., 82(9), pp. 473-6.

Candela, G. (2007). Minilaparotomy versus laparoscopy in the treatment of cholelithiasis: our experience.G Chir., 28(1-2), pp.35-8.

Ghazal, A. H. et al. (2009). Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. 7(4), pp. 338-46.

Guerriero, O. (2008). et al. Laparoscopic surgery for acute cholecystitis in the elderly. Our experience. Chir Ital., 60(2), pp.189-97.

Hodgett, S. E. et al. (2009). Laparoendoscopic single site (LESS) cholecystectomy. J Gastrointest Surg., 13(2),pp.188-92.

Hong, T. H. &, You, Y. K. (2009). Transumbilical single-port laparoscopic cholecystectomy : scarless cholecystectomy. Surg Endosc., pp. 1393-7.

Ibrahim, S. et al. (2006). Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy. World J Surg., 30(9), pp.1698-704.

Ibrahim, S. et al. (2008). Analysis of a structured training programme in laparoscopic cholecystectomy. Langenbecks Arch Surg. 393(6), pp. 943-8.

Jacques, M. et al. (2007). Report of Transluminal Cholecystectomy in a Human Being. Arch Surg., 142(9), pp.823-826.

Ji, W. (2006). Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis. Hepatobiliary Pancreat Dis Int., 5(4), pp. 584-9.

Joris, J. Et al. (2007). Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg, 81, pp. 379–384

Litwin, D & Cahan, N. (2010). Laparoscopic Cholecystectomy. Surgical Clinics of North America, 88(6), pp.1295-1313.

Lukovich, P., Vanca, T. & Gero, D. (2009). The development of laparoscopic technology in light of cholecystectomies performed between 1994 and 2007. Orv Hetil., 150(48), pp. 2189-93.

Malini, R. C. et al. (2008). Microflora of bile aspirates in patients with acute cholecystitis With or without choleliathiasis: a tropical experience. Brazilian Journal of Infectious Diseases, 12 (3), pp. 483_494.

Miguel, A. C., Frits, B. & Alexander, A. F.(2009).The “invisible cholecystectomy”: A transumbilical laparoscopic operation without a scar. Surgical Endoscopy, 23 (40), pp.896-899.

Pardo-Mindan, F. et al. (2008).Eosinophil inflammatory reaction in isolated organs. Allergol Immunopathol, 8, pp. 23-30.

Ros, A. & Carlsson, P. (2009).Non-randomised patients in a cholecystectomy trial: characteristics, procedures, and outcomes. BMC Surg., 26 (6), pp.17.

Syrakos, T. (2007).Small-incision (mini-laparotomy) versus laparoscopic cholecystectomy: a retrospective study in a university hospital. Langenbecks Arch Surg., 389(3):pp. 172-7.

Tacchino, N., Greco, F. & Matera, D. (2010). Single-incision laparoscopic cholecystectomy: surgery without a visible scar. Gastroenterology Research, 3(5), pp.213-231.

Tajima, K. & Katagiri, T. (2009). Deposits of eosinophil granule proteins in eosinophilic cholecystitis and eosinophilic colitis associated with hypereosinophilic syndrome. Dig Dis Sci, 41(4), 282-288.

Tan, J. T. et al. (2006). Prospective audit of laparoscopic cholecystectomy experience at a secondary referral centre in South australia. ANZ J Surg., 76(5), pp. 335-8.

Tanya, A. R. & Sara O. V. (2011). Cholecystitis and Cholelithiasis Associated with an Intramural Fasciitis-Like Proliferation and Osseous Metaplasia. Pediatric and Developmental Pathology, 14 (1), pp. 80-83.

Terlecka J. & Majewski, W. D. (2009). An investigation of the quality of life of female patients operated by laparoscopic or open way for uncomplicated cholecystolithiasis. Ann Acad Med Stetin, 53(1), pp. 43-52.

Tian, Y. et al. (2009). Laparoscopic subtotal cholecystectomy as an alternative procedure designed to prevent bile duct injury: experience of a hospital in northern China. Surg Today, 39(6):510-3.

Vagenas, K. et al. (2006). Mini-laparotomy cholecystectomy versus laparoscopic cholecystectomy: which way to go? Surg Laparosc Endosc Percutan Tech., 16(5), pp. 321-4.

Witzke, D. B. & Gagliardi, R. J. (2007). Laparoscopic surgery: surgical education in the People’s Republic of China: changes after 15 years. Surg Laparosc Endosc Percutan Tech., 17(3), pp.153-5.

Zhi, Y. W. et al. (2007). Prevention of Biliary Duct Injury in Laparoscopic Cholecystectomy Using Optical Fiber Illumination in Common Bile Duct. Surgical Endoscopy, 22(5), pp. 1211-1213.