Care Plan Template
Patient Initials: N/A Age: 65 years old Sex: Female
HPI (History of Present Illness): According to the patient she started experiencing shortness of breath after any kind of activity. In addition, patient started developing dry cough two week prior to seeking medical attention. Two days prior to the history taking, patient had a fever recorded at 101°F.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): Patient has bronchial asthma from her childhood. She was also diagnosed and treated for emphysema in the past. In the 70’s patient underwent a major operation involving the removal of the patient’s uterus—hysterectomy. Patient once encountered an allergy for sulfa drugs which causes rashes. Patient was once treated with antibiotics and inhaler for her emphysema. She also admitted to taking two Tylenol (650mg) for pain as needed.
Significant Family History: Patient also has two older sisters who are both in their 70’s. One is diagnosed with breast cancer and the eldest has osteoporosis.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use) Patient was a retired hairdresser. Attends Church and participate to religious activities from time to time. Patient admits not to do any physical exercise. On her free time, patient wants to go shopping but has no opportunity to do so. Her hobby includes sewing. Patient also admits to smoking a pack of cigarette daily for the past forty years.
Description of Client’s Support System: Patient has two daughters, both are alive and well and are within close proximity to her. However, she only sees them once every month. Patient has hired a caregiver she sees three to four times annually. While patient is a regular church-goer, her contacts with her fellow Church goers are limited to religious activities.
Behavioral or Nonverbal Messages: Patient admits to experiencing depressive mood. She has no one to talk to and could not enjoy an activity with. Although patient wants to see her children as often as possible, she does not want to bring it up with them.
Vital Signs including BMI:
Patient’s blood pressure is high at 130/72 and temperature indicates fever at 101°F. Patient is also boarder line obese with BMI of 30.2 since the normal BMI should only be 30. RR and PR are identified as normal.
Physical Assessment Findings: No lymph nodes detected, no heart murmurs, a decrease breath sound, increase anterior-posterior diameter of the chest wall. Significant findings of white material on the buccal mucosa on patient’s tongue which cannot be removed by a tongue blade suggesting fungal infection.
Lab Tests and Results:
WBC = 15,000 left shift, Pulse oximeter reading = SAO2 98%.
ICD-9 Diagnoses/Client Problems:
4928 – Other emphysema
01231 - Tuberculous laryngitis, bacteriological or histological examination not done
27800 – Obesity, unspecified
V790 - Screening for depression
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
- Patient exhibits risk prone behaviors that needs modification:
- Smoking 1 pack of cigarette a day
- NIC 4360 Behavior modification – assist patient towards behavioral change.
Need to educate patient that her current practice particularly relating to her smoking is posing health risks.
- NIC 4490 Smoking cessation – patient should find the need to stop smoking.
May need to introduce aids that could assist patient to smoking depending on which is effective to her. Referral to a pharmaceutical aid if necessary.
- Obesity, Unspecified
- NIC 4360 Behavior modification – patient needs to monitor her eating according to proportion. Patient has already expressed a healthy eating diet. However, perhaps her weight gain to borderline obesity is caused by her lack of physical activities.
- NIC 1260 Weight Management – While patient reports living and eating healthy patient should be mindful of her weight. The reason why patient was classified as obese while her weight seemed normal is because it is not commensurate to her height. This is why patient’s BMI registered as 30.2.
- Improvement of Health Maintenance as due to ineffective practice
- Insufficient physical activities or exercise
- NIC 0200 Exercise promotion – since the patient is not living in crime propagated community, patient can do some regular walk even just around her street. She can also start walk to church is it is within walking distance.
- NIC 6520 – Health Screening. Patient has repeatedly refuse screening during the entire medical confinement. This is particularly necessary to confirm the diagnosis. Patient should be encouraged to have rounds of laboratories and medical examinations to ensure that the proper treatment is given.
- Ineffective Coping Mechanisms
- NIC 5230 Coping enhancement – patient has been feeling relatively depressed although patient’s stressors could be a result of her retirement from work. Patient was used to working and having people around to talk to. Refer to a counsellor if necessary. Patient should also need to verbalize to her children her needs for social involvement so they can help her.
- NIC 7110 Family Involvement Promotion – Facilitate family participation as patient goes through an emotional phase battling depression. A strong physical, emotional and financial presence of patient’s children could help assist the patient as she goes through the depressive cycle that she was complaining about.
- Airways and breathing management
- NIC 3250 Cough Enhancement – patient has been enduring her cough for more than two weeks. As a result, her lungs are placed under a great amount of pressure. Attending nurse should help promote deep inhalation during this stage to relieve the lungs from that pressure.
- NIC 3350 Respiratory Management – patient reports breathing difficulty. As a result, patient’s breathing should be monitored to check if she is getting adequate supply of air. May necessarily refer the patient to a Respiratory Therapist.
Edwards, J., 2014. Talk Therapies. [Online] Available at: http://www.mentalhealth.org.uk/help-information/mental-health-a-z/T/talking-therapies/
Janz, N. & Becker, M., 1984. The Health Belief Model: A Decade Later. Health Education Behavior, 11(1), pp. 1-47.