This is my psychosocial NPR. I wrote it before professor McFadden explained to us what we had to include in it and surprisingly I passed. I did have a lot of comments on my process record, I’ll write everything she told me to change in the future.



Age 76 (o)
Stated she was diagnosed with COPD “a few month ago” (s)
Stated that uses oxygen at home (s)
Poor appetite, eats only yogurts (o)
New medications prescribed (o)
Has a soar on the gums from new inhaler (o)
Lives with daughter and daughter’s family (s)
Afraid to get OOB to the chair stated “I hope they know what they are doing putting me in the chair” (s)
Gets anxious when in unfamiliar place or with an unfamiliar person (RR 30 when she first saw me) (o)Asked about the difference between COPD, emphysema and Asthma (o)


Deficient knowledge related to new disease processes.
Patient with a new disease process needs to be educated about the disease and medications prescribed to treat the disease. Patient education is a major component of pulmonary rehabilitation and includes broad variety of topics (#7, 695)
Deficient knowledge is the state in which an individual experiences a deficiency in cognitive knowledge or psychomotor skills concerning the condition or treatment. (260)Mrs. AL was recently diagnosed with emphysema and was prescribed new medications. She expresses a desire to learn more about emphysema and Asthma. Displays deficient knowledge about treatments, such as oxygen therapy, inhalers and positioning.




Goal: The patient will understand her medical diagnosis and treatments by the evidence of ability to describe own disease processes, their treatments and importance of these treatments, while under my care.
1.Assess
mental status. (Level of consciousness and orientation)
2. Assess developmental level according to E. Erikson
3. Determine support system.
4. Determine insight into disability.
5.Obtaine education level.
6. Assess readiness to learn.
7.Establish trusting relationships by using verbal and nonverbal therapeutic communication such as restating or paraphrasing, focusing, summarizing and planning
8.Encourage to take Xanax 0.25mg PO prn TID
Teach patient about therapeutic and side effects.
Monitor for therapeutic and side effect
9.Encourge to ask questions
10.Provide positive feedback and avoid negative feedback
11.Teach the importance of proper positioning
12.Explain the disease processes of emphysema and asthma
13.Teach the importance of oxygen therapy, therapeutic effects and side effects
14. Teach proper use of Spiriva and Advair. Instruct to rinse mouth with water after using Advair


1. Assessment of mental status reveals the client’s general cerebral function. (#3, 642) Impaired cognitive ability may affect the client’s capacity for learning. (#3, 492)
2. Nurses can enhance a client’s developmental level by being aware of the individual’s developmental stage and assisting with the development of coping skills related to stressors experienced at that specific level. Nurses can strengthen client’s positive resolution of a developmental task by providing the individual with appropriate opportunities and encouragement (#7, 353) (Said I have to discuss specific level of older adult, explain + & - resolution.)
3. Social support has been demonstrated to be effective moderator of life stress. Social support also facilitates person’s coping behaviors; however, this depends on the nature of the social support. Emotional support from family and significant others provides love and sense of sharing the burden. Being a member of a group with similar problems or goal has a releasing effect on a person that promotes freedom of expression and exchange of ideas.(#7, 107) Spirituality helps people discover a purpose in life, understand the ever-changing quality of life, and develop their relationship with God or higher power. Spirituality is also a component of hope, and, especially during chronic, serious, or terminal illness, patient and their families often find comfort and emotional strength in their religious traditions or spiritual beliefs.(#7, 122) There are also cultural barriers to learning, such as language or values. To be effective, nurses must be culturally sensitive and competent; otherwise the client may be partially or totally noncompliant with recommended treatments. (#3, 492)
4.Learning is easier if a learner can connect the new knowledge to what they already know and have experienced (#3, 490) (Didn’t like rationale)
5. Because of decreased length of hospital stays, time constrains on client education may occur. Some of the education therefore will have to receive through reading. Patient’s ability is therefore important. Ability to use other sources, such as internet is also important. (#3,490)
6. Readiness to learn is the demonstration of behaviors or cues that reflect the learner’s motivation to learn at a specific time. For example if a patient is in pain or anxious she might not be able to learn. (#3, 490)
7.Lack of trust in patient-nurse relationship may create anxiety and interfere with learning.(#3, 489) Actively listening for the client’s messages and then repeating those thoughts and or feelings in a similar words conveys that the nurse has listened and understood the client’s basic message. Focusing helps the patient to expand on and develop a topic of importance. Summarizing and planning is useful at the end of an interview or to review a health teaching session. It often acts as an introduction to future care planning. (#3, 470)
8. Xanax is an anxiolitic; it is used to treat mild-to-severe anxiety. It is contraindicated for patients with renal or hepatic dysfunction unless no other options are available. Adverse effects include headache, dry mouth, blurred vision dizziness, hypotension, GI disturbances (e.g., nausea, constipation), jaundice, incontinency, urinary retention, rash, and leucopenia. (#4, 179)
9. Learning is faster and retention is better when learner actively participates. (#3, 490)
10. Positive reinforcement increases the probability of positive response to teaching and increases motivation (#3, 489). Negative feedback is viewed as a punishment and may cause the patient to avoid the person providing negative feedback in order to avoid punishment (#3, 491)
11. High Fowlers position is the position of choice for people who have difficulty breathing. It’s better to elevate the head of the bed or transfer a patient to the chair instead of placing an overly large pillow or more then one pillow behind the client’s head. this promotes the development of neck flexion contractures (#3, 1132)
12. One of the complications of emphysema is right-sided heart failure. Congestion, dependent edema, distended neck veins, or pain in the region of the liver suggests the development of cardiac failure. Patient should be aware of these complications (#3, 687). Complications of asthma may include status asthmaticus, respiratory failure, pneumonia, and atelectasis. Airway obstruction, particularly during acute asthmatic episodes, often results in hypoxemia, requiring the administration of oxygen and monitoring of pulse oximetry and ABG (#3, 711).
13. Suplemental oxygen is effective in prolonged survival of patients with COPD, however, when supplemental oxygen is administered at a rate higher then necessary, increased oxygen saturation results, and CO2is unable to be carried by hemoglobin or is cast off by the hemoglobin. This results in an overall increased load of CO2 in the body. (#3, 694)
14. Spiriva/Tiotropium is used to treat COPD, it is an anticholinergic agent. It works by enlarging the airways to allow easier breathing. Capsule is used with a specific inhaler and should not be swallowed. Capsules should not be exposed to air for long periods of time, if while removing the capsule, the second capsule was exposed to the air, it must be discarded. Some medicines may interact with Spiriva; therefore mouth should be rinsed after using this medication. (#8)
Advair/Fluticasone/SalmeterolFluticasone is a steroid. It prevents the release of substances in the body that cause inflammation. Salmeterol is a bronchodilator. It works by relaxing muscles in the airways to improve breathing.Advair is used to prevent asthma attacks. It will not treat an asthma attack that has already begun. To reduce the chance of developing a yeast infection in your mouth, rinse with water after using Advair. Do not swallow (#1)


1.Awake alert and oriented x3
2. I assessed developmental level according to E. Erikson.
3. Patient reported living with daughter and daughter’s family. Patient reported she is not a member of a support group. I didn’t refer her to the support group, but I should’ve informed her about lung association support groups in New York (American Lung Association of New York State -- Albany Office. 155 Washington Ave., Suite 210 Albany, NY 12210. 518) 465-2013 x300 and American Lung Association of New York State -- Long Island Office700 Veterans Memorial Highway Hauppauge, NY 11788. (631) 265-3848) Patient is roman catholic. She goes to the church where she can communicate with others and get support. (Left a huge comment about how great it was that I included it. So if u have McFadden, and want to make her happy with your NPR, include referral.)
4. I asked patient to explain to me all she knows about emphysema and asthma. Asked her to list medications she is taking and their effects.
5. Obtained education level. Education – high school. Patient can read, but stated she can not use internet.
6. Patient was too anxious to learn on Wednesday however was ready to learn on Thursday. She expressed desire to learn and felt less anxious after seeing me a many times over two days.
7. I established trusting relationships by using therapeutic communication techniques such as paraphrasing (so your daughter and her family moved in with you to help you out after your husband died), planning (lets review what you learned about use of your oxygen and you can then take a few deep breathes and try to cough), and summarizing (I will come back tomorrow and explain you more about ways to improve your breathing).
8. Xanax was not given due to low blood pressure, however the patient was not anxious when teaching was initiated and therefore was unnecessary.
9.I encouraged the patient to ask questions
10. I provided positive feedback when the patient was correctly summarizing learned information. I did not provide negative feedback
11. I explained the importance of proper positioning and explained that sitting in the chair would allow greater chest expansion and lung ventilation.
12. I answered patient’s question regarding the difference between COPD, emphysema and asthma. I explained disease processes of emphysema and asthma and listed complications patient might develop and should be aware of. I also explained that COPD places her at risk for pneumonia and she should be vaccinated in order to prevent it.
13. I explained the importance of proper use of oxygen therapy and explained why the patient should not increase oxygen flow unless necessary. I also reminded about fire safety.
14. I explained the proper use of Spiriva and Advair, reasons to receiving it, its action and the side effects. I instructed to rinse mouth after using Advair


1. Mental status indicates that the patient is able to learn and retain new information.
2. Older adult. Integrity vs. despair. Patient stated she is usually very active and takes care of grandchildren while her daughter is at work, however was in despair while hospitalized due to worsening of her condition. As condition started to improve, integrity was returned.
3. The patient can get more information from other members of the community; her family can also help her to find the information about new medications and disease processes.(Asked to elaborate on how I know her family can help her with internet use)
4. Patient knew very little about emphysema. She didn’t know the difference between emphysema, COPD and asthma. Patient listed all of her pulmonary medications and was able to list most of the side effects. This shows that she needs a lot of teaching about the condition while little education about medications is needed.
5. Patient is able to read the brochures about COPD and asthma, even though patient doesn’t know how to use internet, family can help her find the needed information online.
6. Very little teaching was done on Wednesday. Most of the teaching was done on Thursday when the patient was less anxious and more willing to learn.
7. Patient was not as anxious when talking to me as she was when she first saw me. Her respiratory rate decreased from 30 to 18. Patient was able to retain information better after trusting relationships were established.
8. If Xanax would’ve been given, I would’ve expected that patient would have change in respiratory rate, blood pressure and reported decrease in anxiety.
9. Patient asked questions about COPD, emphysema and asthma. Teaching proved to be more efficient when patient asked for the information, patient was more willing to learn.
10. Patient was willing to learn and retained information much faster then by the end of the day then she did when I first attempted teaching.
11. Patient stated “I suppose you are right, I will try to sit in the chair when physical therapist will come”
12. Patient reported understanding. Stated that she already was vaccinated last fall. She summarized received information and was able to list symptoms of the most serious complications.
13. Patient was surprised to find out that increased oxygen flow can be harmful, she stated she only uses oxygen at home only when she has to and will continue using it only when necessary unless her condition worsens. Reported understanding of fire hazards, stated that she no longer smokes and her family members don’t smoke inside the house.
14. Patient reported understanding, she stated that she always rinses mouth after receiving Advair, but doesn’t rinse after Spiriva Because she usually takes Spiriva right before Advair and they don’t interact.

She also wanted me to elaborate more on teaching nd give specific examples.


Bibliography
1) “Advair.” Drugs.com. 8 Jan. 2008. 21.Feb. 2008 http://www.drugs.com/search.php ?searchtrm=advair&is_main_search=1.
2) Karch, Amy M. Nursing Drug Guide. Rochester: Lippincott Williams & Wilkins, 2008.
3) Kozier, B., Erb, G., Berman, A., Snyder, S., Fundamentals of Nursing Concepts, Process and Practice, 8th ed., new York, Addison-Wesley, 2008 (a/k/a Prentice Hall)
4) McCuistion, Linda E., and Kathleen J. Gutierrez. Saunders Nursing Survival Guide: Pharmacology. 2nd ed. St. Louis: Saunders-Elsevier, Inc, 2007
6) Pagana, Kathleen D., and Timothy J. Pagana. Mosby's Manual of Diagnostic and Labratory Tests. 2nd ed. St. Louis: Mosby, 2002.
7) Smeltzer, S., Bare, B., et al, Brunner and Suddarth’s Textbook of Medical Surgical Nursing, 11th ed., Philadelphia, J.B. Lippincott Co., 2008
8) "Spiriva." Drugs.Com. 8 Jan. 2008. 21 Feb. 2008 .