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 .

This is the first NPR I passed this semester. Format isn't the same as you can see, but I'm sure you will be able to figure it out though. This NPR was submitted to professor McFadden.
Ineffective airway clearance related to stasis of secretions secondary to pneumonia
Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms including bacteria. Pneumonia affects both ventilation and diffusion. An inflammatory reaction can occur in alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide. White blood cells also migrate into the alveoli and fill the normally air-containing spaces. Areas of the lungs are not adequately ventilated because of secretions and mucosal edema that causes partial occlusion of the bronchi or alveoli.(#4, 634)
Ineffective airway clearance is the state in which an individual experiences a threat to respiratory status related to inability to cough effectively.Mrs. PT has pneumonia; she has a stasis of pulmonary secretions. Therefore she has an ineffective airway clearance.



COPD (o)
Pneumonia (o)
Productive cough (o)
Rhonchi (o)
Shortness of breath when talking and coughing (o)
Use of accessory muscles (o)
Pulse ox – 91 (o)
O2 3L/min nasal cannula (o)
Pulse ox drops to 80 when nasal cannula is off for more then 5 min. (o)
Restlessness (o)
Anorexia, unable to access amount consumed due to time restrains, however, patient reported she doesn’t have an appetite and eats very little (s)
Impaired physical mobility (o)
Weakness (o)
Pallor (o)
Irregular labored respirations (o)
Yellow thick sputum with small amount of blood (o)
Age – 81 (o)
Cancer (o)



Goal: The patient will maintain patent airway while in my care.
1a.Assess respirations.
1b. Assess pulse
1c. Assess blood pressure
1d. Assess temperature
1e. Assess pain
2. Assess oxygen saturation.
3. Auscultate lung sounds
4. Assess mental status
5. Assess skin color
6. Assess coughing and sputum.
7. Assess lab values
8. Educate patient and family about therapeutic effects and side effects of oxygen therapy Maintain oxygen therapy as prescribed (3L/min via nasal cannula)
Monitor for therapeutic effects
9. Provide appropriate positioning
10. Provide chest PT
11. Teach deep breathing and coughing
12. Increase fluid intake (2-3L/day small frequents amounts)
13. Promote rest
14. Teach patient and family about therapeutic effects and side effects of Vancomycin. Administer Vancomycin 500mg q6h. Monitor for therapeutic effects. Monitor for side effects
15. Teach patient and family about therapeutic and side effects. Administer DuoNeb as prescribed (3mL QID). Monitor for therapeutic effects. Monitor for side effects
16. Teach patient and family about therapeutic effects and side effects of Aranesp. Administer Aranesp as prescribed (5000 units/wk)
Monitor for therapeutic effects.
Monitor for side effects
17. Teach patient and family about therapeutic effects and side effects of Ambien. Administer Ambien as prescribed (10mg prn HS) monitor for therapeutic effects and side effects.
18. Maintain adequate nutrition
19. Provide teaching
The only change in goal and care plan she wanted me to make is to list therapeutic and side effects of the medications in steps 14-17



1a. Dyspnea, use of accessory muscles, difficulty breathing, irregular respirations, and other changes in respirations are associated with pneumonia. Respiratory symptoms may be the only signs of pneumonia in patients with COPD (#7, 724) (I don't know what she meant by it, but she wrote "How does hypoxia effects respirations?" I thought it was obvious, but I guess she wanted me to elaborate more on it)
1b. Dysrhythmia is a sign of hypoxemia. Hypoxemia usually leads to hypoxia, which is life threatening. Tachycardia is a sign of hypoxia. (#7, 724)
1c. Unusual increase in blood pressure may be a sign of hypoxia (#7, 724)
1d. Patients with certain types of pneumonia (pneumococcal) usually have a sudden onset of chills and rapidly rising fever (38.5 to 40.5 C or 101 to 105 F) Patients who have conditions such as cancer and have a suppressed immune system are more likely to have fever(#7, 636)
1e. Patients with pneumonia often have pleuritic chest pain that is aggravated by deep breathing and coughing. Some patients experience signs of respiratory tract infection such as sore throat (#7, 636)
2. Pulse oximetry is performed to determine the need for oxygen and to evaluate the effectiveness of the therapy. Pulse oximetry can help to determine the need for oxygen therapy. High concentration of oxygen is contraindicated in the patients with COPD because it may worsen alveolar ventilation by decreasing the patient’s ventilatory drive, leading to further respiratory decompensation. However if oxygen saturation is too low, more aggressive respiratory support measures may be required. (#7, 638)
3. Adventitious lung sounds such as rhonchi and crackles are often present during pneumonia and indicate presence of fluid and pulmonary secretions in the lungs. (#7, 643)
4. Changes in mental status, such as impaired judgment, agitation, disorientation, confusion, lethargy, and coma are signs of hypoxia. If hypoxia is not identified and treated early many complications and even death may occur. (#7, 724)
5. In severe pneumonia, cheeks are flushed and lips and nail beds are cyanotic demonstrating central cyanosis (A late sign of hypoxia) (#7, 636)
6. Patients with pneumonia often have cough. When cough is productive and sputum is expectorated, sputum is often purulent. Rusty, blood tinged sputum may be expectorated with streptococcal (pneumococcal) staphylococcal, and Klebsiela pneumonia.Purulent sputum may be the only signs of pneumonia in patients with COPD (#7, 640)
7. Blood culture may be taken to determine whether bacteremia is present (#6, 670). Sputum culture is used to diagnose pneumonia. Gram stain is the first step in the microbiologic analysis of sputum. This may be used to guide drug therapy until the C&S report is complete. Determinations of bacterial sensitivity to various antibiotics are performed to identify the most appropriate antimicrobial drug therapy (#6, 716) Blood smear provides information concerning drugs and diseases that affect the RBCs and WBCs. Further more many diseases can be diagnosed by an examination of the peripheral blood smear. (#6, 672)
8. A high concentration of oxygen is contraindicated for patient with COPD because it worsens alveolar ventilation by decreasing the patient’s ventilatory drive, leading to further respiratory decompensation. Not enough oxygen however may cause oxygen saturation to drop. (#7, 638)
9. The patient should assume a comfortable position (semi-Fowler’s or high-Fowlers) and change positions frequently to enhance secretion clearance and ventilation and perfusion in the lungs. (#7, 640)When the patient is in Fowler’s position, gravity pulls the diaphragm downward, allowing greater chest expansion and lung ventilation. (#3, 1132)
10. Chest physiotherapy is important in loosing and mobilizing secretions. Indications for physiotherapy include sputum retention not responding to spontaneous or direct cough, a history of pulmonary problems previous treated with chest physiotherapy, continued evidence of retained secretions (decreased or abnormal breath sounds, change in vital signs), abnormal chest x-ray findings. (#7, 640)
11. Lung expansion maneuvers, such as deep breathing may induce a cough. A direct cough may be necessary to improve airway patency. (#7, 640)
12. Hydration is a necessary part of therapy, because fever and tachypnea may result in insensible fluid loss.
Adequate hydration can also thiner and loosen pulmonary secretions Hydration must be achieved more slowly and with careful monitoring in older adults and patients with preexisting conditions, such as CHF. (#7, 640)
13. It is important to instruct patient not to overexert herself and engage in only moderate activity to preserve energy. (#7, 640)
14. Vancomycin is a bactericidal. It inhibits cell wall synthesis of susceptible organisms, causing cell death. It is given to patients with staphylococci infection who cannot receive or failed to respond to penicillin and cephalosporins. (#5, 48)
15. DuoNeb is a bronchodilator that relaxes muscles in the airways and increase air flow to the lungs.DuoNeb is used to prevent bronchospasm in people with chronic obstructive pulmonary disease (COPD) who are also using other medicines to control their condition. (#1)
16. Aranesp is a medication used for treating anemia in people who are undergoing chemotherapy or have chronic kidney failure. It is a man-made version of a human protein that stimulates the production of red blood cells by the bone marrow (#5)
17. Ambien is a sedative-hypnotic, or sleep medicine. It works by helping to increase certain natural chemicals in the brain that cause sleep. (#4, 183)
18. Many patients with shortness of breath and fatigue have a decreased appetite and consume only fluids. Proteins however are needed to fight the infection. Supplements such as Ensure might be used to increase caloric intake.(#7, 640)
19. The patient and her family need information about factors that may have contributed to development of pneumonia and strategies to promote recovery and prevent recurrence. (#7, 641)


1a. Assessed respiration: Semi-Fowler’s position: Rate – 22/min, regular, shallow.
Use of accessory muscles. Shortness of breath when talking and coughingSitting in a chair: rate-20/min, regular, use of accessory muscles. Depth became deeper while in the chair.
1b. Assessed pulse: Rate-86.
Rhythm- regularVolume- weak
1c. Assessed blood pressure of 130/64
1d. Assessed temperature of 96.3 at 9:30 and 96.5 at 11:00. (She wrote "do not record readings this low. Must take again or use a diff. route" I took temperature orally, and the patient was mouth breather, should've taken axillary and added 1 to the result)
1e. Assessed pain of 4. Patient described it as sharp, stated it “disappears and comes back” when she moves around. Patient described the location as being in the back of the groin.
2. Assessed oxygen saturation of 91 when in semi-fowler’s position, 93 in sitting position and 94 after receiving bronchodilators. All readings were taken while the patient was receiving 02 at 3L/min via nasal cannula.
3. Assessed lung sounds. Rhonchi before receiving bronchodilators and clear after bronchodilators were administered.
4. Patient was alert and oriented X 3
5. Skin appeared pale while in semi-Fowler’s position, however pink color returned after patient was sited in the chair and received bronchodilators
6. Patient had a productive cough, was able to expectorate sputum.
7. Blood culture was not taken. Sputum culture showed staphylococci bacterial infection. RBC count is 3.70L. WBC count is 3.6L. HGB is 10.8L, HCT is 34.6
8. Oxygen was given at 3L/min by nasal cannula. I taught the patient about therapeutic effects and side effects. Explained the need to maintain oxygen therapy as prescribed and not to increase the dose unless the condition worsens and more oxygen is needed to maintain adequate oxygenation. Monitored therapeutic effects.
9. Head of the bed was elevated to position the patient in low-Fowler’s position. Was later transferred to the chair.
10. Provided chest physiotherapy during bed-bath.
11. Taught to deep breath and cough during the bed-bath.
12. Explained the need to increase fluid intake, the patient drank frequently, small amounts of water to prevent fluid overload.
13. Provided bed-bath, patient brushed her teeth, the rest of the am care was done by me. Cut food for the patient.
14. Explained to the patient importance of following doctor’s orders. Explained how Vancomycin can help to kill bacteria causing pneumonia and how bacteria can become resistant to the Vancomycin if treatment is stopped before all pneumonia causing bacteria are dead. Vancomycin was administered by primary nurse Unable to access the therapeutic effects due to time restrains. No common side effects have been reported. The patient had no signs of allergic reaction to Vancomycin
15. Taught patient about bronchdialecting effects of DuoNeb listed side effects and sign of allergic reaction. Advised to check with your doctor if any of these common side effects persist or become bothersome: Coughing, dizziness, dry mouth, headache, nervousness, sinus inflammation, sore throat.
Advised to seek medical attention right away if any of these severe side effects occur: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); chest pain; fast or irregular heartbeat; new or worsening breathing problems; pounding in the chest; shortness of breath; swelling of the arms or legs; tremors; unexplained hoarseness; wheezing. DuoNeb was administered by the nurse. I monitored therapeutic effects, and side effects.
16. Explained the effects of Aranesp and the importance of having sufficient RBC count in oxygen transport. Listed side effects and explained that the patient should be aware of the signs of CVA and MI since they are adverse effects of Aranesp. Aranesp was administered by primary nurse. Was unable to monitor therapeutic effect due to time restraint.Monitored for side effects
17. I taught the patient about therapeutic effects of Ambien and the importance of having a good night sleep in order to maintain active and productive life style. I also explained the importance of safe use of sleep medications and effects of other prescribed medications on sleep. Listed side effects of Ambien such as memory loss, anxiety, depression, agitation, aggression, suicidal thoughts. Ambien was administered by primary nurse.
Was unable to assess the therapeutic effects myself due to time restraints however patient was able to explain that Ambien was not effective.Was unable to monitor for immediate side effects, however I asked the patient to recall if she had any side effects of this medication.
18. Patient was served food rich in proteins. Food was cut for the patient to conserve her energy. Some of the food was removed from the tray and saved for later
19. Taught about factors that may contribute to development of pneumonia and strategies to promote recovery and prevent recurrence, such as hydration, nutrition, coughing, oxygen therapy and use medications
She wanted me to start writing "I assessed/ positioned" and so on.


1a. Although respiratory rate was within a normal range, other respiratory assessments indicate that the patient had difficulty breathing. According to change in rate and depth of respirations, patient experienced less discomfort when sitting up.
1b. No sign of hypoxia or hypoxemia are present.
1c. Although the blood pressure is slightly elevated, it could be a result of hypertension patient was diagnosed with. Other adaptetions have to be assessed to determine if elevated blood pressure is a result of hypoxia.
1d. Patient is afebrile. This could’ve resulted from effects of medications.
1e. Pain is most likely a result of cancer. A tumor was found in the spleen.
2. According to pulse oximetry test, change in positioning and bronchodilators were helpful in improving oxygen saturation. Even tough oxygen saturation in low Fowlers position is low; drop is not significant enough and could be accounted by inaccuracy of pulls oximetry reading
3. Lung sounds indicate that bronchodilators were effective.
4. No change in mental status was noticed. Patient does not show signs of hypoxia
5. Patient had one of the signs of hypoxia, however oxygen saturation was improved by change in positioning and bronchodilators
6. Thick yellow sputum with small amount of blood was expectorated between 9 and 10am. No blood was present later in the day; however sputum remained thick regardless of increased fluid intake. Consistency of sputum indicated that hydration was ineffective, or not enough time was given for changes to occur.
7. Sputum culture determined antimicrobial agent to be used in treatment. RBC, and Hgb are low, therefore oxygen is not delivered to the tissue in sufficient quantities. WBC count is low, possibly as a result of cancer treatment. WBCs are needed to fight the infection, low WBC count indicates that the host is compromised and is unable to fight an infection on her own.
8. Pulse oximetry showed 91% oxygen saturation in the beginning of the day (while in bed with the head of the bed elevated 45º, however changed to 93% while sitting and 94% after receiving bronchodilators.Didn’t obtain Pulse oximetry without oxygen therapy, patient was too short of breath and decreasing oxygen provided to the lungs would place the patient in risk of hypoxia.
9. Started coughing when was repositioned. Stated she felt much better and could breath easier when was sitting in the chair. Fell asleep while in the chair. Stated she couldn’t sleep because it was hard for her to breath in a lower position (low-Fowler.) Oxygen saturation increased from 91 while in bed to 93 while in the chair. Respirations became deeper when the patient was sited.
10. The patient started to cough and expectorated pulmonary secretions after the chest physiotherapy.
11. Patient was deep breathing every hour. Deep breathing resulted in productive cough every time deep breathing was initiated. The patient was also taking deep breaths during auscultation, productive cough resulted.
12. Sputum was thick throughout the time patient was in my care. The patient continued complaining of mouth dryness possibly resulting from mouth breathing. The patient also complained her nares were dry due to use of nasal cannula
13. Patient was fatigued. Had difficulty breathing while talking and coughing, however was able to preserve energy for breathing instead of using it for hygiene and food preparation.
14. Patient reported understanding therapeutic and side effects of Vancomycin. She listed all side effects and therapeutic effects. She also explained the reason to follow doctors orders and take all of the Vancomycin she was prescribed. Unable to establish effectiveness due to time limitations. However if more time was available, I would’ve monitored WBC count, sputum culture results, monitored breathing patterns and cough. No common side effects have been reported. The patient had no signs of allergic reaction to Vancomycin
15. Patient reported understanding of therapeutic and side effects of DuoNeb. She listed all side effects and therapeutic effects Patient reported being able to breathe easier, lung sounds became clear after DuoNeb was administered. Patient complained of dry mouth and was coughing, however both signs were present before the medication was given, therefore could be caused by other stressors.
16. Unable to assess effects due to limited time frame, however if more time was given, I would’ve monitored RBC count. The patient had RBC count of 3.70 on 1/31/08 which is low. RBC are important in oxygen transport. RBC count is not directly related to airway clearance, however the lower RBC count is, the more important airway clearance becomes. No side effects present
17. Patient reported understanding of therapeutic and side effects of Ambien as well as the importance of adequate sleep and proper use of sleep medications. Patient stated she was unable to sleep all night. Stated she was sleeping only 4 hours at night regardless of sleep medication administered before sleep. Patient stated she didn’t experience any side effects of this medication
18. Unable to monitor amount consumed due to time restrains. However patient stated she has a poor appetite.
19. Patient reported understanding and stated she will consume more water, deep breath, eat small frequent meals, and consume energy. Reported understanding of medical treatments prescribed
Goal summary: Goal was partially achieved, patient still had stasis of secretions partially obstructing airflow, however was able to maintain opened airway and removed some of the secretions through coughing. Deep breathing and coughing exercise, chest pt and positioning were helpful in removing the secretions, bronchodilators helped to open the air way by increasing the diameter of bronchioles. Further assessments are needed to evaluate effectiveness of treatments that need more time to be effective. Due to time restrains however, I was unable to assess effectiveness of some of the treatments.


On the last page she listed 5 main changes I had to make.
1. "Col 1 - Need to increase (s) data"
2. "Col 2 - integration of Pt with her specific adaptations (cluster) from col 1. summarize why your pt. is appropriate for your selected N.D."
3. "N.I. - teaching" (I guess she wanted more teaching)
4. "Must assess prior to teaching"
5. "Reassessments have to be done at the end of NCP"


Bibl.
Bibliography
1) “DuoNeb.” Drugs.com. 8 Jan. 2008. 4 Feb. 2008 http://www.drugs.com/duoneb.html.
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) McCance, Kathryn L., and Sue E. Huether. Pathophysiology, the Biologic Basis for Disease in Adults and Children. 3rd ed. St. Louis: Mosby, 1998.
5) Monsom, Kristi, and Arthur Schoenstadt. “Arenesp.” MedTV. 23 Sept. 2007. 5 Feb. 2008 http://cancer.emedtv.com/aranesp/aranesp.html.
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

Nursing in NCC

Nursing program in Nassau Community Collage is very hard both to get into and to stay in. I am now into my second semester and so far doing well, however I have seen many people struggling with process records and tests. Some of the steps that have to be included in the care plan are vital signs, medications, lab work, and teaching. There are times when some of these steps are not applicable for the specific patient, but without them included, process record can be failed. The easiest way to get around it is by writing that step should have been taken, but wasn’t for a specific reason, then explain what the result would’ve been if the step would’ve been taken. For example one of my patients who had poor peripheral perfusion was on Lovenox, unfortunately for me it was DCed the day I got the patient. It was the only medicine she had that would’ve had helped her with perfusion. In intervention column I stated that Lovenox was DCed and added that if the patient would’ve still been on Lovenox, I would’ve monitored her for bleeding. In evaluation column I explained that if it would’ve been given, I would’ve expected changes in PT/INR. The same patient had dementia and was dehydrated which did its share of damage to her mental status. Of cause teaching would be impossible or at least pointless for this patient, which is why I break teaching into a few steps. First step is “assess mental status” and across the columns I described that due to deterioration of cerebral cortex secondary to dementia, patient is awake and oriented times 1, I then explained that mental status assessments showed that patient is unable to learn and retain new information. I will post some of my process records in near future, as well as bibliography, hope this will help all the future nurses to get through the nightmare of getting through nursing program. If you have any questions please do ask. I’ll be happy to help (that is if I can of cause).