nursing process paper

B. Parker
Prof. Fern Baudo
December 4, 2013

Nursing Process Paper

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Managing ineffective health maintenance in a patient with multiple chronic illnesses.

Overview. M.E.P. is a 37 year old African-American female who came to the ER on
September 20, complaining of widespread severe body pain, shortness of breath, weakness, extreme fatigue, and a fever. In the ER, the physicians admitted her to inpatient care with two diagnoses: sickle cell anemia crisis and mycoplasmic pneumonia. M.E.P., by her own account, spends most of her time in the hospital, but even while inpatient she is constantly surrounded by her very large, expressive family. The client and her family are cooperative, pleasant people who show visible emotional support for one another. The staff and family both state that during the patient’s frequent stays, she is never left by herself and usually has 2-3 visitors in her private inpatient room. She has a history of several medical issues, such as sickle cell anemia, diastolic heart failure, SLE, asthma, bronchitis, heart block, mitral & tricuspid regurgitation, diabetes mellitus (type 2) and CVA (stroke).
Pathophysiology. Sickle cell disease or sickle cell anemia (often shortened to SCD or SCA) is a hereditary disorder of the blood in which many red blood cells do not assume the classic “donut without a hole” shape, and instead develop into a sort of long, banana-shaped “sickle” cell. The genetic difference leaves the affected person resistant to malaria, but does lend them toward situations that are commonly referred to as “sickle cell crisis”, which usually involves vascular backup or blockage (a result of the RBC’s irregular shape and inability to move normally within the vasculature) that can cause organ damage, ischemia or necrosis — which are often very painful experiences for the client. SLE, systemic lupus erythematosis or simply “Lupus”, is an auto-immune disorder that results in cellular attacks against one’s own body tissue, which causes hypersensitivity, inflammation and tissue damage. Bronchitis is an inflammation of the bronchioles, and can cause problems with airway clearance as a result of the swelling involved.
Diabetes mellitus is a chronic condition that is mainly a result of the body’s inability to produce

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enough insulin to process the sugars that are ingested and would normally be converted into energy for the body’s use. Mitral and tricuspid regurgitation can result from previous heart tissue injury or genetic defects in the structure of the patient’s heart. A CVA or cerebrovascular accident is often referred to as a “mini-stroke” or a “brain attack”, and is an event in which a vascular blockage or sclerosis has decreased the circulation to an area of the brain, resulting in brief ischemia which did not result in permanent damage to the brain or brain tissue necrosis
(which would instead be called a “stroke” event). Mycoplasmic pneumonia is caused by a fungal bacteria that is resistant to many forms of antibiotic therapy. Outbreaks of this type of pneumonia are commonly found in areas of long-term and recurrent population congestion, such as schools, military bases, urban housing projects and colleges.
Management. According to the textbook, nursing management of SCA focuses on pain control. [MORE ABOUT NURSING MANAGEMENT OF THAT DISEASE HERE].
According to the textbook, nursing management of SLE focuses on [ISSUE]. [MORE
ABOUT NURSING MANAGEMENT OF THAT DISEASE HERE].
According to the textbook, nursing management of chronic bronchitis focuses on [ISSUE].
[MORE ABOUT NURSING MANAGEMENT OF THAT DISEASE HERE].
According to the textbook, nursing management of mycoplasmic pneumonia focuses on
[ISSUE]. [MORE ABOUT NURSING MANAGEMENT OF THAT DISEASE HERE].
According to the textbook, nursing management of a patient with a past CVA focuses on monitoring for changes in blood pressure and neurological response. Taking the patient’s vital signs (including blood pressure) as ordered by the HCP will help ensure that the patient’s BP is monitored sufficiently. Performing neurological checks and assessments as required by the doctor can help to monitor the patient for neurological changes so that interventions can be performed and the MD can be contacted if necessary.
Assessment. Upon entering her room to introduce myself and perform my initial assessment,
I noticed that her 3 visitors (one of whom was a small child) were not wearing masks as required by the facility regarding droplet precautions for her mycoplasmic pneumonia. I verified her name, date of birth and allergies, before asking if she knew the date and why she was in the hospital. She replied with correct information, which allowed me to confirm that she was alert and oriented. I then asked her how she was feeling. I noticed that she was mildly winded in her response, and inquired as to why she was not wearing her oxygen (3 liters via nasal cannula), and
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she responded that she frequently forgets to put it back on after she takes it off to visit the restroom. I counted her respirations at an even 20 breaths per minute, and mostly regularly spaced except for a few brief moments of apparent dyspnea. I assessed her room air oxygen saturation, replaced her oxygen, and measured it again. I discovered diminished breath sounds in the RLL, RML, and LLL of her lungs, as well as rhonchi upon exhalation in her RML. After listening to her lungs, I talked to her about her substance use history. While she denied using alcohol or illicit drugs currently, she admitted to a history of drug abuse, and current treatment with methadone. Her family told me in private that she does not take her methadone, but instead sells it. She also admits to smoking a half a pack of cigarettes per day, for the past 15 years; she proudly states that she has not smoked since her admission into the hospital, nor has she requested any sort of nicotine replacement measure. She mentioned that she had been looking into vapor cigarettes, and claims she feels they’d be healthier for her — but asserts that she
“cannot quit” smoking because her husband “smokes inside the house constantly”, despite having home oxygen that she is expected to have on continuously.
I then took her vital signs, which were all within normal limits except her oxygen saturation on room air, which was 84%. When wearing her 3 liters, the result elevated to 98%. The client reported that she also uses 3 liters of oxygen via nasal cannula at her home. She was afebrile, with an oral temperature of 98.4 degrees Fahrenheit. Her blood pressure and pulse were
128/82 and 96 respectively. I inquired toward her level of pain or discomfort, and M.E.P. admitted that she was feeling very uncomfortable and rated her body pain at a 7-8/10. She stated that she tried to stay still and not exert herself too much. She found that her pain and discomfort was lessened when she limited her activity to short walks down the hallway, or trips to the restroom in her room. She said she spent most of her time sitting in the reclining chair provided by the facility, but during the evenings she would retire to her bed. In checking her pulses and range of motion, I found both to be within normal limits, having +5 strength in all extremities, +2 pulses in all sites, and full active range of motion in all major joints.
When talking about her elimination habits, she stated that she last used the restroom three days ago, and described it as “not much”. She went on to say that it was very hard, dark in color, and pellet like. Upon auscultation, her bowel sounds were present but hypoactive in all four quadrants. The patient admitted to ignoring the dietary restrictions her HPC had prescribed on several occasions recently. Within the last week, she describes two situations in which she chose to
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go against the advice of her provider; one in which she ate a salad when she was NPO to rule out a bowel obstruction after an incident in which she had vomited stool, and a second - when she’d eaten a couple of donuts when she was supposed to be restricted to clear liquids. I witnessed firsthand this tendency to circumvent her dietary restrictions, as I watched her consume fast food meals (brought to her by her family members) consisting of burgers, french fries and “regular” soda (as opposed to diet), which is not in any way within her recommended low sodium (2g Na), low fat, diabetic diet. The client had completed a couple of diagnostic tests recently as ordered, a
CT of the chest and a lung perfusion scan was performed earlier on in the week. These were done to assess for gas exchange abilities and for airway clearance issues.
Nursing diagnosis. The data collected during my assessment led me the nursing diagnosis of
“ineffective health maintenance” related to a lack of compliance with her prescribed health regimen. This is evidenced by her non-adherence to dietary restrictions, failure to use oxygen properly, safely and as directed by her provider, failure to adhere to droplet precautions, selling her medications instead of using them, and cigarette smoking. The nursing goal I decided to set was to help the patient display and practice improved and effective health maintenance habits.
To achieve this goal, I set three positive outcomes to work toward. In accomplishing these three positive outcomes, I hope to help the client display enhanced knowledge, increased compliance and a heightened awareness of the dedication required to establish healthy habits to protect herself from preventable complications related to her diseases.
Nursing Goals. The first outcome to be achieved is that the patient will display increased understanding of her health issues, including the mycoplasmic pneumonia, diabetes mellitus, and sickle cell disease processes, as well as problems that can be encountered with small bowel obstructions. To display her newly acquired knowledge by asking her to list or explain one contributing factor for each of her illnesses (pneumonia, diabetes and sickle cell), and three ways she plans to minimize the risks. In addition, the patient will be able to explain the reason for droplet precautions and display compliance by ensuring that all visitors wear masks in her room by the end of the clinical day at 1600. The second outcome to accomplish is that the patient will show increased understanding of and compliance with treatments by having zero non-compliant episodes, and verbalizing three benefits of compliance and/or drawbacks of non-compliance with respect to her disease process by the end of the clinical day at 1600. The third positive outcome we’ve aspired to is that the patient will participate in her own health-improvement by
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assisting in designing her home routine. She will do this by identifying five ways she has been non-compliant in the past with treatment and healthcare management while at home, and identify five ways she will change her home environment to improve her overall health management and compliance by the end of the clinical day at 1600.
Interventions. Now that the goals and positive outcomes are set, the focus can shift to how we plan to arrive at our destination. First, I spoke to the patient about precipitating factors of sickle cell crisis (including stress, infectious illnesses, hypoxia, dehydration, excessive exercise and low body/environmental temperatures.) Teaching the patient about the controllable contributing factors to sickle cell crisis can help her to identify her behaviors that might cause sickle cell crisis or exacerbate her sickle cell disease.
Then we discussed pneumonia and its effect on her lungs. I taught her how to use the incentive spirometer and instruct her to use it 10 times each hour minimum. Teaching the patient about pneumonia and steps she can take herself to improve her lung expansion improves understanding of the disease and empowers the patient to care for herself. Afterwards, I explained the purpose of droplet precautions and why they are necessary for the type of pneumonia she has (mycoplasmic) and why it is important for her visitors (especially small children) to wear masks upon entry to her room (and for HER to wear a mask upon exiting her room.) Further explanation of the purpose of the precautions may help her understand the necessity for them, and encourage compliance to protect herself and others (especially her loved ones).
Next, I explained to the patient that visitor compliance with droplet precautions is mandatory and that it is also her responsibility (as well as the staff ’s) to remind all visitors of this policy, and ensure that visitors remain masked even during extended visits. Staff should perform spot checks for mask compliance when visitors are present in the room. Delegating the enforcement of the mask policy for droplet precautions empowers the patient and makes her "in charge" of this aspect of her care.
Spot checks will either confirm that expectations are being met or indicate a need for further instruction and enforcement. I provided masks directly outside the room for both adult and child visitors (since the patient's children and family members visit her often) and posted a large sign on the door asking that all visitors wear masks upon entry & see the nurse with any questions about the mask policy.
Providing easily noticed and accessible masks and a reminder sign prevents noncompliance due to inability to remember or access proper equipment. I provided smoking cessation education via written material for her to review with her husband. We discussed the risks secondhand smoke pose to her health
(even if she were to quit and he were to continue to smoke) & how environmental stressors are also a precipitating factor to sickle cell crisis. I answered any questions she or her husband had at
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the time. Including her husband in the smoking cessation discussion may increase his understanding of her disease processes and reinforce the necessity for the patient to quit smoking and prevent further exposure to cigarettes and cigarette smoke by living in a smoke free environment. I also talked to patient about why "vapor cigarettes" are not an appropriate alternative to smoking cessation, and how nicotine affects her cardiac and vascular health (while incorporating her diabetes mellitus type 2 in the vascular health discussion.) The client believed that because of her respiratory issues, vapor cigarettes were an appropriate choice for her. She lacked knowledge of nicotine's other effects on the body (such as that of the cardiovascular system) and how nicotine would compound her current health problems and increase her risk of further complications regardless of the method of use. Explaining the risks could encourage her to commit to quit smoking instead of just switching to electronic cigarettes and continuing nicotine use.
I discussed the possible effects of dietary non-compliance with regard to intestinal blockage or bowel sluggishness, and the effect of narcotic pain medications on bowel movement. I will explain that NPO means "nothing by mouth" and that it is a safety measure instated to prevent harm until bowel obstruction is ruled out. Outlining the purpose of restricting her oral intake until obstruction is ruled out may encourage her to comply once she understands the risks involved & confirm her understanding. Explaining how her pain medications impact her bowels may help her understand why she is having problems moving her bowels regularly. I explained how improper dietary maintenance can contribute to poor blood glucose control, and discussed what long term complications could arise from poor blood glucose control (blindness, poor vascular health/circulation, etc). Making her aware of the risks involved in poor diabetic maintenance and compliance may encourage her to decide to make more informed, responsible, healthy choices about the foods she eats. I encouraged the patient to describe an average day at home: what she eats, how many cigarettes she smokes, when she uses oxygen, when she feels short of breath, what activities she engages in and for how long. Making a list of things she normally does will help make it easier to identify non-compliant behaviors that necessitate adjustment or change in habit. I helped the patient use the description above to identify incidences of non-compliance, and asked the patient to explain why that behavior is detrimental to her health maintenance. Asking the patient to identify a non-compliant behavior and explain why it is detrimental enhances understanding and encourages problem solving (working toward a solution or a plan to change). I asked the patient to think of one way they can alter, augment or completely change their routine to turn the non-compliant habit into a compliant, health conscious behavior. This encourages problem solving. and empowers the patient to take control of their own health maintenance. It helps them practice making healthier choices (with guidance.) I
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encouraged the patient to choose a trusted family member to remind her and check to ensure that she is taking all medications on schedule and appropriately & following dietary restrictions as specified. This may help to encourage & engage the family to act as a support system, and help to reinforce accountability of the patient with regard to her own health maintenance.
Outcome and Evaluation. After implementing all of the proposed nursing measures and interventions, the patient was able to verbalize knowledge of common sickle cell crisis causes and precipitating factors. She discussed possible tactics for avoiding those factors and situations, and whether or not they were realistic for her life, commitments and schedule. The patient was able to verbalize knowledge of the purpose of her droplet precautions, basic knowledge of her pneumonia diagnosis and its effect on her lungs' ability to fully expand, and was even receptive to using the incentive spirometer, which she used ten times each hour on the second clinical day.
She did not take it upon herself to enforce visitor mask compliance, as several visitors were witnessed in her room without masks on. To fully meet this goal, I need to monitor her visitors more carefully, and when I observe noncompliance, reinforce that it is her responsibility to ensure compliance in her visitors. To ensure safety, it may be necessary to restrict the number of visitors allowed in her room at one time (she had up to 10 at once at one point during the day) until she displays that she is able to enforce the droplet precautions herself without being reminded. The patient was able to verbalize two benefits of compliance and two drawbacks of non-compliance.
She did, however, have two episodes of non-compliance on day two of clinical, and numerous episodes on day one. She continued to allow her visitors to be noncompliant regarding droplet precautions and mask wearing. To meet this goal, I need to sit next to the door to her room and offer a mask (and education re: how to wear the mask properly) and an explanation for why the mask is important to each visitor. I would need to open the blind to her room to monitor compliance and intervene when I observe a visitor without a mask on until 100% compliance is met. The patient was able to identify three ways she has been non-compliant in the past with regard to health maintenance while at home. She did discuss one way she could possibly alter her lifestyle to correct each noncompliant habit and adopt a healthier alternative behavior. To meet this goal, I would engage her in a discussion about how non-compliant behavior has adversely affected her health. I would encourage her to talk about ways she adheres to her regimen in the hospital, and ask her about how that differs from her behavior at home. Then, I would encourage
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her to write down how she could begin to emulate the compliant behavior she has in the hospital even after her discharge, and ask her what types of changes that will require in her home environment. NURSING PROCESS PAPER

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