Nursing Plan of Care Nursing Plan of Care In the diagnosis process, a patient’s medical history and physical assessment is vital in ascertaining his/ her condition. Evelyn Riley’s case scenario is a typical example of a clinical situation that requires these elements, physical assessment and medical history. Doctors or physicians utilize numerous techniques in performing a clinical assessment. In Evelyn’s case, I would explain to the student about the assessment process and its relevant techniques including a visual and physical examination, which is required to assess Evelyn’s body organs visually. The organs include head, neck, nose, mouth, and throat. The visual assessment will encompass looking for anomalous shape, color, size, texture among other aspects. Generally, nurses utilize physical assessment expertise and skills to identify the patient’s problems and develop a basis of data and information, which are utilized for subsequent nursing processes (Cox amp. Turner, 2010). I will explain to the student the assessment techniques that are involved in the physical assessment including palpation, percussion and auscultation. Palpation incorporates the utilization of hands to feel the body organs in enabling the assessment of abnormal shape, size, level and location of pain. On the other hand, Percussion incorporates the generation of sound by scrapping or tapping the body part in order to determine the parameters including the organ density and size (Cox amp. Turner, 2010). Consequently, auscultation entails listening to sound produced by various organs like the throat and lungs. These are the assessment techniques utilized in Evelyn’s scenario:Assessment Techniques The order of the assessment techniques includes Inspection. Palpation. Percussion and lastly Auscultation: A. Inspection Critical observation is conducted first whereby the nurse takes appropriate time in observing the patient with all senses including eyes, nose and ears. In this process, the nurse must utilize good lightning in order to ascertain his observation on color, shape, position and symmetry. Consequently, observation for odors of skin and mouth is essential (Sawyer, 2012). B. Palpation In this process, deep (5-8 cm) and light (1 cm) touch by the back of the nurse’s hand (or fingers) is utilized to assess the patient’s skin temperature. Consequently, use fingers to inspect the moisture, tender areas and texture. C. Percussion This is an essential part of the physical assessment where by the nurse strikes the body surface to generate sound. The following sounds. resonant, dull, flat and tympanic are utilized to determine shape and size of underlining structures in the relevant body organs (Sawyer, 2012).D. Auscultation This assessment mostly utilizes a stethoscope for indirect auscultation but in obvious cases, nurses listen to sounds generated by specific body organs. The direct auscultation entails listening to the service user from a given distance or by resting the ear on the skin’s surface (Sawyer, 2012). Nursing care Plan for Evelyn after assessment38 years oldA single mom with three children, an lives with two of themWorks full time and spends most of her free time with her children and sickly grandson Ryan who is seems undernourishedAfter caring for her grandson who had a terrible cold , she developed a cold tooComplains of a sore throat , head pain and coughingHer head pain is centered over her head Upper teeth and jaws hurtThe pain aggravates in the morning and exhausting activities worsens the head pain Recording The SOAP method is utilized in the case scenario to assist in the data recording to effectively complete a reliable entry. The format utilized in recording the data entails: S- Subjective data: record the patient’s condition, which will include the characteristics of pain and aggravating factors. O- Objective findings: the physical assessment evidence generated from the examination is then recorded regarding the condition of the patient.A- Assessment: record of the nurse’s assessment of subjective and objective findings, and complaints is included.P- Plan- entails the nurse’s plan for current and future treatment.Influenza (flu) Diagnosis A nursing plan is developed to tackle a nursing diagnosis of influenza based on symptoms of influenza including cough, fever, cold, sore throat and head pain. Onset severe sign and symptoms also include diminished breathing sounds, a lucid nasal discharge, reddened nose and enlarged lymph nodes. The nursing diagnoses are:Risk for deficient fluid in the body as a result of dehydration and, Ineffective airway clearance due to secret build up and inflammation The nursing interventions may include helping the patient to cough up the suctioning or secretions. It is also recommended for the patient to rest until influenza is resolved fully. The patient should drink a lot of water to deal with dehydration. Antiviral treatment, which is essential in the treatment or prevention of flu, can help in tackling the conditions. However, the medicine fails to eliminate the influenza symptoms. though, it is essential in reducing the duration and severity of the symptoms (Ladwig amp. Ackley, 2013). Patient education Patients with influenza must have a high level of personal hygiene, especially respiratory hygiene. Respiratory hygiene will entail putting on a mask when coughing as well as coughing into tissues and sleeves. Consequently, Evelyn should wash her hands regularly especially after coughing (Carpenito, 2009). In order to regulate and control seasonal influenza, immunization has proven to be an effective way. Therefore, annual immunization and vaccination are vital preventive measure that Evelyn can utilize. The client education strategy will encompass a one-on-one communication process whereby the nurse will explain the prevention measures Evelyn ought to undertake (Doenges, Moorhouse amp. Murr, 2013). The effectiveness of the educational intervention will be known when Evelyn will not report back to the clinic with same symptoms of influenza. ReferencesCarpenito, L. J. (2009).Nursing care plans amp. documentation: Nursing diagnoses and collaborative problems. Philadelphia: Wolters Kluwer Health/Lippincott Williams amp. Wilkins.Cox, C. L., amp. Turner, R. (2010).Physical assessment for nurses. Chichester, West Sussex, U.K: Wiley-Blackwell. Doenges, M. E., Moorhouse, M. F., amp. Murr, A. C. (2013).Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia: F.A. Davis.Ladwig, G. B., amp. Ackley, B. J. (2013).Mosbys guide to nursing diagnosis. Maryland Heights, Missouri: Elsevier. Sawyer, S. (2012).Pediatric physical examination amp. health assessment. Sudbury, MA: Jones amp. Bartlett Learning.
Plan of Care