The primary aim shall be focused on the critical health issues affecting the ABC's (airway, breathing and circulation) of life, where wellness shall be promoted, discomfort be alleviated and complications be prevented with in the duration of her stay inside the hospital. As part of a nurse's care, an effective well comprehended discharge plan shall be discussed both to the patient's daughter as well as the patient herself for home treatment. One of the most important tasks that a nurse assumes in the medical industry is to make sure that the patient shows optimum if not maximum health conditions prior to discharge. It also her duty to provide health education unto the patient and the patients significant others for a thorough out patient care, one that is understood by both in terms of semantics, relevance and importance so as to be religiously followed.
Admitted to my ward 3 days post surgery, 77 years old Patient Tee is currently in 2 litres oxygen therapy with 99% saturation via nasal prong. Chest x-ray indicates that the lower lobe of the lung has collapsed with a sputum microscopy that revealed a few gram positive Vancomycin resistant enterococcus. The patient also suffers from dysphagia characterized by post swallowing cough as well as dysphonia. Physical mobility is likewise restricted possibly due to fatigue and or fear of pain. While patients pre-hospitalization history already reveals poor nutrition, as verified by her daughter's statement that the patient refuses to eat her meals, this is much heightened with the presence of dysphagia (Medline and Mayo clinic home page. 2006). The patient's micro culture and sensitivity results tested positive on Enterococcus species, although there is no sign of elevated temperature as of the moment.
The initial focused assessment that shall be made by interviewing patient Tee's of her present condition in order to gather information related to how and what she is feeling, taking into consideration dysphagia, pain (if any), breathing and communication ability, her appetite, urine and bowel movement, and the reasons for inability and her description of the intensity of pain/discomfort, as part of my acquisition of subjective data. As a nurse the observation that will take into account my own objective assessment will include, her breathing pattern, willingness to move about, range of movement, coherence and affect; her response to touch as well as the psychological manifestation of how she feels about her recent conditions and finally verifying this observations with laboratory results
Nursing Diagnosis with rationale:
Ineffective breathing pattern and impaired gas exchange secondary to collapse of the left lower lobe of the lung as evidenced by the decrease in oxygen saturation in the blood whenever oxygen pattern is removed (Orem, 1980. p.11). Activity intolerance related to shortness of breath as well as fatigue related to impaired oxygen exchange system. Anxiety related to feeling of suffocation and possible fear related to disabling respiratory deficiency. Impaired verbal communication secondary to dependence of prong/masked O2 inhalation and lastly chronic or situational low self esteem related to loss of normal