Centennial College Practical Nursing Theory 1 PNUR 104-701 Focused Nursing Care Plan – Group Assignm

Centennial College Practical Nursing Theory 1 PNUR 104-701 Focused Nursing Care Plan – Group Assignment Jenn Mansley October 20, 2024 Submitted by: Amalia Pabon Alvarez 301189634 Aminat Adedokun 3013104547 Anika Singh 301470984 Hayat AbdulRahman 301259313 Kazzia Abbott-Cornwall 301252919 Case Study: Don is a 56-year-old man who has come to his family doctor’s office complaining of a cold that has lasted for over three weeks. He is allergic to penicillin and nuts. On assessment he is afebrile, breath sounds equal and clear bilaterally, RR 18, HR 84, BP 130/70. He complains of nasal congestion and an intermittent dry cough in the evening. When speaking with Don he shares that he was recently laid off from his job and is having trouble finding another. He loved his job and is unsure what to do with his time now. He is worried about finances because he has a small pension that he can’t use until he is 65. He is receiving some government financial assistance which he says is “barely enough to pay rent.” He lives in a 5th floor apartment and lives alone since his wife died 10 years ago. He has a brother who lives close by, but they haven’t talked in years. Don says “we just grew apart”. His son moved out west 5 years ago and Don states his son “has his own life now, I don’t want to bother him with my problems”. Don used to socialize regularly at the local community center, but stopped going during the first COVID lockdown. Don has been eating poorly, saying, “I can’t afford to buy much food” and eats three small meals a day. He visits the food bank weekly and says he drinks water with his meals. He hasn’t showered and his clothes are dirty. He says he had a bath last week. His hair is shoulder length, oily and matted at the back. You notice his fingernails are rough with dirt under the nails. His skin is dry, and scaly and there is a fissure on his right heel. His lips are dry and cracked and he has bleeding gums. You notice he has halitosis, and he says he has not been to a dentist in years. This Assessment Collection and Data Analysis table should be used as a template and can be modified to meet your needs. Use this assessment tool to gather pertinent data and conduct your assessment and analysis in any manner that you want. However, ensure that your work is presented in a way that is clear and organized. Priority Need with rationale: State the Priority Need and explain why you have selected this as your priority Need. Oxygenation: Don has a prolonged cold, nasal congestion and a dry cough that can lead to a respiratory tract infection if not treated. Subjective Data Objective Data 56 years Not been to a dentist in years Not showered Not eating regularly Does not speak to his brother Laid off from his job Cold lasting over 3 weeks Allergic to penicillin and nuts Nasal congestion and intermittent dry cough Worried about finances Vital signs (HR 84, RR 18, BP 130/70) Afebrile Dry, scaly skin Fissure on right heel Bleeding gums Rough fingernails with dirt underneath Hair matted, oily at the back Dirty Clothes Dry, Cracked lips Halitosis Data(s) Analysis Data Cluster: Prolonged cold Nasal congestion intermittent dry cough in the evening SKB: Coughing is a reflex triggered by irritation in the airways, throat, or lungs. A dry cough occurs when there is no mucus production, often caused by irritation. Having a cold in people of Don’s age is very common, the number of functional cilia is reduced, causing a decrease in the effectiveness of the cough mechanism, putting him at increased risk for respiratory infections such as bronchitis or pneumonia. (Potter et al 2023, p.969). NKB: Nurse should look out for any other symptoms such as breathing difficulty or sore throat, Assess respiratory rate and his level of hydration, Determine the type (Productive or unproductive) and frequency of the cough, Ask about his vaccination status for flu, Covid, Nurse should ask about any exposure to tuberculosis (TB) and the results of the tuberculin skin test if available(Potter et al 2023, p.968). Analysis: Prolonged symptoms of cold (lasting over three weeks) combined with reduced cough efficiency increases the risk of respiratory complications/Infection. Don’s body due to aging might be unable to effectively resist pathogens in the upper respiratory tract, increasing the chance of getting into the lower respiratory system, leading to bronchitis or pneumonia. Nurse should take a proactive approach in providing care to Don, to prevent further decline in his respiratory health. Data Pattern: Drinks water with his meal SKB: Patients with nasal congestion experience evaporation of fluid in the airway due to mouth breathing. Hydration is important for restoring fluid loss from respiratory evaporation and lubricating the airway (Potter et al., 2023, 979). NKB: Nurse should educate Don on the importance of staying hydrated, and commend Don for drinking water with his meals. Analysis: Don is at risk of ineffective hydration and fluid loss, related to breathing with his mouth due to nasal congestion. Don’s nursing care plan should be directed towards keeping him hydrated as to minimize compromised respiratory system symptoms. Data Norm: 56 year old SKB: The pts immune system strength weakens with age, older adults are more susceptible to flu, colds, and infections. Infections in older persons are increased by age-related reductions in immune system response (Potter et al., 2023, p. 429). NKB: Pt is an older adult, nurse should educate pt on different methods to prevent colds such as wearing a mask and performing hand hygiene to protect themself and prevent the spread of infection. Nurse should assess pt for related cold symptoms such as wheezing, sneezing, and nasal secretions. Analysis: Don is at risk of developing secondary illnesses such as pneumonia due to age related immunity and his cold. Nurse should continue to monitor pt for further symptoms and provide treatment that will aid in clearing the respiratory system. Nurse should take the necessary precautions to prevent worsening pts condition due to weakened immune system. Data Gap: He is allergic to penicillin and nuts Rationale: Incomplete allergy history, there is no clarification of the severity of reactions to penicillin,this information is needed in his medical information if he will be taking antibiotics in the future. There are also various types of nuts, which specific types is he allergic to – Hazel, peanuts? This is crucial to be able to plan and manage his diet. SKB: It is important to understand the severity and seriousness of an allergy in order to administer medication safely and to insure safe treatment . patients face the danger of experiencing series reaction if their allergy history is incomplete NKB: I Analysis: Data Cue: dirt under fingernails. Inference: dirty fingernails house bacteria and viruses which can lead to transfer of common cold pathogens into the respiratory system by touching the face, nose or mouth. SKB: The common cold is caused by rhinoviruses and other viruses, which are transmitted by direct contact with infected surfaces or direct person-to-person transmission via respiratory droplets. The chances of self-inoculation are greater when hygiene is poor and the pts dirty hands and fingernails may harbor cold viruses that enter his respiratory tract when he touches his face or nose.. (Potter et al., 2023,p. 141) NKB: Nurse should ask Pt about hygiene habits, educate the Pt on maintaining cleanliness, and explore any existing barriers that may prevent him from maintaining personal hygiene. These may include financial barriers, low motivation due to grief and social isolation, or even limited access to hygiene products. (Potter et al., 2023, p. 903). Analysis: The pts poor hygiene is a contributing factor to the persistence of cold symptoms. The physical examination of the patient showed normal vital signs without fever; however, his overall body hygiene is compromising his already weakening immune system. Using the care plan template provided here, develop a nursing care plan based on the case study. â–ºIdentify One NANDA Priority Nursing Diagnosis â–ºDevelop One (1) Expected outcome (Patient Goal) based on your priority nursing diagnosis â–ºDetermine Three (3) Nursing Interventions with rationale for the expected outcome Priority Nursing Diagnosis Expected Outcome Interventions Rationale for intervention Risk of respiratory tract infection r/t nasal congestion, prolonged cold and unproductive coughing. Patient will be free of cold and breathe through their nose without any congestion by discharge. Nurse will teach patient effective cough techniques at 1200H today. Coughing techniques will help to clear the airway effectively and decrease fatigue from unproductive coughing.(Potter et al 2023, p.977). Nurse will teach clt how to use nasal instillation spray to decongest the sinus and to relieve cold symptoms at 1500H today. Self-administering sprays is easier because the patient can control the spray and inhale as it enters the nasal passages. (Potter et al 2023, p.760). Nurse will place a humidifier near the head of the pts bed at 1200H today. Air or oxygen with a high relative humidity keeps the airways moist and helps loosen and mobilize pulmonary secretions. (Potter et al 2023, p.980). References Marieb, E. N., & Keller, S. M. (2023). Essentials of Human Anatomy & Physiology (13th ed.). Pearson. Astle, B. (2023). Potter and Perry’s Canadian Fundamentals of Nursing (7th ed.). Elsevier do the data gap and add refrecnce add reference for the data gap my part is to do the data gap ADD PAGE NUMBER ON EACH SKB NKB AND ANALYSIS

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