ncp for breathing

7/25/2019 NCP for Breathing

1/17

ICA CASE STUDY 1

BREATHING

SUB GROUP 4 :

CELESTE , HIDAYAH , KELLY , NABILAH , SASI , XIAO HUI , YU XING


2/17

Defne and Explain Breathlessness Identiy Objective and Subjective data related to

breathlessness

List o Other History

Analyse the data iven and list do!n the potentnursin proble"s associated to breathlessness

Identiy Expected Outco"es to evaluate e#ectivnursin interventions

Describe appropriate nursin care or $r %uso a

explain the rationales behind it&


3/17

'ASE S()D%

$r %uso* a ++ , year , old retiree* is ad"itted t"edical !ard ro" the e"erency depart"enprovisional dianosis is pneu"onia& He co"pla

breathlessness and has a productive couh& He appanxious and tired& He is unable to provide his "edicHis !ie ans!ers or hi" instead !hile hesits* leathe bedside table& She says that he has been cou

reenish sputu" over the past - days&


4/17


5/17


6/17

'ASE S()D% ;'O


7/17

'lient51atient de"oraphic daName Mr Yusof

@ender $ale

Address uron est Street 82

Birthdate 2838

1lace o birth Sinapore

6ace $alay

Ae ++ years old

$arital status $arried

1ri"ary careiver ie

1rovider o history ie

Ad"ission date 7- uly 742?

Hihest educationallevel

)n>no!n

Occupation 6enovation supervisor


8/17

6easons o See>in Health'are

6easons or

co"in to hospital

Breathlessness

'hie co"plaints 1roductive couh

Dianosis 1neu"onia


9/17

Explorin 'hie 'o"plaint usin OLOnset Breathlessness , productive cough , green

sputum

Location 'hest tihtness ro" the re:uent couh

Duration (hree days'haracteristic* severity

1atient has been couhin out reenish sputu"the past - days

Aravatinactors

S"o>in 24 , 2? stic>s per day since 2+ years

6elievinactors

Sits * lean over table

(reat"ent Oxyen 7/9 via a ace "as>Oral antibiotics erythro"ycin ?44ra" every +hours ;to treat pneu"onia=Oral paraceta"ol 2ra" every + hours ;to reduever=

Bed rest


10/17

Current Medication(medication that the ED

has given beforeadmitting to our ward)

Oral antibioticsErythromycin

Oral Paracetamol

Past medical/surgicalhistory

None

Family History NIL

Social History Worked as a renovationsupervisorLives with wife nochildrenSmokes cigarettes sinceage of !" years smokes

!#$!% sticks per day


11/17

Normal breathing

Spo7. 8? , 2449

Shortness of breath (SOB)

It is a eelin o diCcult or laboured breathin that cancaused by certain acute or sudden onset conditions&

It is a sensation o diCculty or unco"ortable breathin

hat isBreathlessness


12/17

Other History ; hat other ALs are a#ecte!ell=

Objective data Subjective data

$r %uso is havin a ever o -/&-0 '& Ho! lon has $r %uso havin the ever

Did $r %uso ta>e any "edicto reduce his ever

Objective data Subjective data

1ain score o 3524 'o"plained o chest tihtne Does $r %uso still eel pain

!hen couhin fts have sto

Controlling Body emperature

Sleeping


13/17

$aster proble" list

!roblem "ate identi#ed "ate resolve

Ine#ective

Breathin 1attern;Actual 1roble"=

7- uly 742?

Ine#ective Air!ay'learance;1otential 1roble"=

7- uly 742?

no!lede Defcit;Actual 1roble"=

7- uly 742?

Fever 7- uly 742?

1 ti t bl 2 I # ti B


14/17

1atient proble" 2. Ine#ective Brea1attern$ssessment %oal &

e'pectedoutcome ()

*nterventions +ational

Subjective Data.

$r %uso co"plainso breathlessness& $r %usoGs !ie

"ention he has beencouhin outreenish sputu"&

His !ie ans!eredhis "edical history

or hi"&

Objective Data. )se o accessory

"uscles 66 7/ bp";


15/17

1atient proble" 7 . Ine#ective Air!ay $ssessment %oal &

'pectedOutcome ()

*nterventions +ationale

Subjective Data. $r %uso co"plainso breathlessness&

$r %usoGs !ie"ention he hasbeen couhin outreenish sputu"&

His !ie ans!ered

his "edical historyor hi"&

Objective Data. )se o accessory

"uscles 66 7/ bp";


16/17

$ssessment %oal &e'pectedoutcome ()

*nterventions +ationale

SubjectiveData. S"o>in

since ae o2+

242? stic>sper day

(oreduce5eli"inate >no!lededefcit&

Educate $r%uso ho! bads"o>in is tohis health andreardin hisillness&

$r %uso >no!s abouthe seriousness o hs"o>in attitude anho! it !ill a#ect hishealth&

Educate $r%uso !hat is

pneu"onia andho! is ita#ectin hishealth and!or>&

$r %uso >no!s !hapneu"onia is and ho

to prevent lunsirritation !hen !or>

(o ensure thetreat"ent iven

is accurate

As> patientGsrelative to

peror" returnde"o or

$r %usoGs relatives chelp to understand o

his illness* conditionand treat"ent

1atient 1roble" - .no!lede De


17/17

6eerences

Mera* $& ;7427=& 5 Pneumonia Nursing Care Plans6etrieved ro"http.55nurseslabs&co"5pneu"onianursincare

Mera* $& ;742-=& 5 Chronic Obstructive PulmonaryDisease (COPD) Nursing Care Plans& 6etrieved

http.55nurseslabs&co"5?chronicobstructivepuldiseasecopdnursincareplans5Sabtu& ;742-= Inefective Airway Clearance& 6etrie

ro"http.55nursininterventionsrationales&blospot&s

4N5ine#ectiveair!ayclearance&ht"l
http://nurseslabs.com/pneumonia-nursing-care-plans/http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/http://nurseslabs.com/pneumonia-nursing-care-plans/

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