Sheridan College NURS NURS-27721 – Develop a comprehensive Nursing Care Plan

CASE STUDY SCENARIO 

Mr. McClaren is a 48-year-old man who is admitted to the emergency department (ED) with abdominal pain and general weakness. He reports that he drinks “one bottle of scotch whisky every week for the past one year, and one to two cans of beer during the weekends.” For the past three months, his condition has started to deteriorate. His wife claims that “he has not been eating well for the past three months”. Mr. McClaren reports he has passed dark red stool on three occasions – the last one being just one day before coming to ED. On examination, Mr. McClaren has an enlarged abdomen with tenderness upon palpation.

He also presents with the following clinical manifestations: peripheral edema, pale yellow skin color, dry mucus membranes and body weakness. The physician suspects that Mr. McClaren has hepatic cirrhosis. His vital sign findings include: Temperature 37.8 Celsius, BP 94/52, Pulse 110, Oxygen saturation 94%. From your nursing classes, you know that some of the treatments Mr. McClaren may receive are paracentesis, ultrasound and CT scan of the abdomen, as well as vitamin K administration.

Nursing Care Plan

Part 1: Identify one priority nursing problem (actual problem not “at risk”) and formulate one appropriate NANDA nursing diagnosis based on the case study. Provide rationale to explain why this is a priority problem based on the case study. Use appropriate source of information (from case study and literatures) to support your answer.

Part 2: Develop a comprehensive Nursing Care Plan using the Nursing Care Plan Template. Follow the evaluation criteria of the rubric when formulating the Nursing Care Plan.

Nursing Essay Sample Nursing Care Plan

Part 1: Nursing Diagnosis

Priority Nursing Problem: Impaired Gas Exchange related to decreased oxygen saturation and compromised pulmonary function as evidenced by decreased oxygen saturation (94%) and tachycardia (pulse rate of 110).

Rationale: The patient’s decreased oxygen saturation and tachycardia indicate a potential problem with gas exchange. Hepatic cirrhosis can lead to the development of hepatopulmonary syndrome, a condition characterized by impaired gas exchange due to abnormal pulmonary vasodilation and intrapulmonary shunting. This can result in decreased oxygen saturation and increased pulmonary vascular resistance, leading to tachycardia. In this case, the patient’s symptoms of peripheral edema, pale yellow skin color, and dry mucus membranes suggest hepatic cirrhosis, which can contribute to impaired gas exchange. Addressing impaired gas exchange is a priority because it can lead to hypoxemia and further compromise the patient’s overall condition.

Nursing Diagnosis: Impaired Gas Exchange related to hepatopulmonary syndrome and compromised pulmonary function.

Part 2: Nursing Care Plan

Nursing Diagnosis: Impaired Gas Exchange related to hepatopulmonary syndrome and compromised pulmonary function.

Goals:
1. Improve oxygenation and maintain oxygen saturation within a target range.
2. Promote effective airway clearance.
3. Enhance the patient’s understanding of self-care measures to improve gas exchange.

Interventions:

1. Monitor respiratory status:
– Assess respiratory rate, depth, and effort regularly.
– Monitor oxygen saturation using pulse oximetry.
– Auscultate lung sounds to identify any abnormal breath sounds.
– Monitor vital signs, particularly heart rate and blood pressure.

2. Provide supplemental oxygen therapy:
– Administer oxygen therapy as prescribed to maintain oxygen saturation within the target range.
– Monitor the patient’s response to oxygen therapy and adjust the flow rate as necessary.

3. Positioning and mobilization:
– Encourage the patient to assume an upright or semi-Fowler’s position to optimize lung expansion.
– Assist the patient with turning and repositioning regularly to prevent complications such as atelectasis.

4. Promote effective airway clearance:
– Encourage the patient to perform deep breathing exercises and coughing techniques.
– Teach the patient the proper use of incentive spirometry to improve lung function.
– Administer prescribed bronchodilators and mucolytic agents as ordered.

5. Provide education and support:
– Educate the patient and family about the importance of smoking cessation and avoiding exposure to respiratory irritants.
– Teach the patient about lifestyle modifications, such as maintaining adequate hydration and avoiding excessive alcohol consumption.
– Collaborate with the interdisciplinary team to provide information and resources for pulmonary rehabilitation programs.

Evaluation:

1. The patient’s oxygen saturation remains within the target range (e.g., ≥95%).
2. The patient demonstrates improved respiratory status, including decreased respiratory rate and improved breath sounds.
3. The patient demonstrates understanding and ability to perform effective airway clearance techniques.
4. The patient verbalizes understanding of self-care measures to optimize gas exchange.

Note: This nursing care plan is a general guideline and should be individualized according to the patient’s specific needs, medical condition, and healthcare facility protocols.