Please read the enclosed case studies below: Prepare Nursing SBAR communication report Situation: Background: Assessment: Recommendation: 2. Prepare careplan based on Patient information: Listing: 3 Nanda Nursing Diagnosis using related to and As evidenced By, the 3 step method, 3 nursing intervention 3 for each nursing Diagnosis and 1 patient goal
Title: Nursing SBAR Communication Report and Care Plan Development
Introduction:
In this assignment, we will analyze two case studies and develop a Nursing SBAR (Situation, Background, Assessment, Recommendation) communication report for each scenario. Additionally, we will create a comprehensive care plan based on the patient information provided in the case studies.
Case Study 1:
Situation:
A 65-year-old male patient with a history of chronic obstructive pulmonary disease (COPD) was admitted to the hospital with increased shortness of breath and difficulty in breathing. The patient has a long-standing smoking history and reports increased coughing with purulent sputum production. The healthcare team suspects the patient may be experiencing an exacerbation of COPD.
Background:
The patient has a medical history of COPD, hypertension, and diabetes. He is currently on medications for these conditions, including inhalers for COPD management. The patient lives alone and has limited family support. He is a retired smoker and has a history of non-compliance with prescribed medications and lifestyle modifications.
Assessment:
Upon assessment, the patient is visibly in respiratory distress, with increased work of breathing, cyanosis (bluish discoloration of lips and nailbeds), and diminished breath sounds on auscultation. The patient’s oxygen saturation is 88% on room air. He is mildly tachycardic with a heart rate of 110 beats per minute, and his blood pressure is elevated at 160/90 mmHg. The patient’s respiratory rate is 30 breaths per minute, which is higher than normal.
Recommendation:
Based on the findings, it is crucial to initiate immediate interventions to manage the patient’s exacerbation of COPD. The healthcare team should administer supplemental oxygen via nasal cannula to maintain adequate oxygenation and improve the patient’s oxygen saturation. Additionally, the patient will need nebulized bronchodilator therapy to relieve bronchospasm and improve airway clearance.
Case Study 2:
Situation:
A post-surgical patient, a 45-year-old female, has been admitted to the surgical ward from the post-anesthesia care unit (PACU). The patient underwent an appendectomy and is now recovering from the procedure.
Background:
The patient is otherwise healthy and has no significant medical history. She is not allergic to any medications and has a normal BMI (Body Mass Index). The patient has a supportive family who will be available to assist her during the recovery process.
Assessment:
The patient is now awake, alert, and oriented. Her vital signs are stable, with a blood pressure of 120/80 mmHg, heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% on room air. The surgical incision site appears clean and intact, with no signs of redness, swelling, or drainage. The patient reports pain at the incision site, rating it as a 5 out of 10 on the pain scale.
Recommendation:
Considering the patient’s stable post-operative condition, the healthcare team should focus on pain management and wound healing. Non-pharmacological pain relief methods such as deep breathing exercises, relaxation techniques, and heat therapy should be initiated. The patient can also be provided with oral pain medication as per the surgeon’s prescription. The incision site should be assessed regularly for signs of infection, and appropriate wound care should be provided.
Care Plan Development:
Based on the patient information provided in each case study, the following care plan will be developed. It includes three NANDA (North American Nursing Diagnosis Association) nursing diagnoses, three related nursing interventions for each diagnosis, and one patient goal.
Case Study 1:
Nursing Diagnosis: Impaired Gas Exchange related to COPD exacerbation, as evidenced by cyanosis, increased work of breathing, and decreased oxygen saturation.
1. Interventions:
a. Administer supplemental oxygen as prescribed to maintain oxygen saturation above 92%.
b. Monitor respiratory rate, rhythm, and effort regularly.
c. Teach patient and family about the importance of smoking cessation to improve gas exchange.
2. Nursing Diagnosis: Ineffective Airway Clearance related to bronchospasm and increased sputum production, as evidenced by increased coughing and purulent sputum.
1. Interventions:
a. Administer nebulized bronchodilators as prescribed to relieve bronchospasm.
b. Encourage deep breathing exercises and effective coughing techniques.
c. Encourage adequate hydration to facilitate expectoration of sputum.
3. Nursing Diagnosis: Ineffective Self-Health Management related to non-compliance with medications and lifestyle modifications, as evidenced by the patient’s smoking history and lack of adherence to prescribed treatments.
1. Interventions:
a. Educate the patient about the harmful effects of smoking and the importance of smoking cessation.
b. Provide information about COPD medications, their proper usage, and potential side effects.
c. Encourage the patient to participate in a pulmonary rehabilitation program to improve self-management skills.
Case Study 2:
Nursing Diagnosis: Acute Pain related to surgical incision, as evidenced by the patient’s self-report and pain rating.
1. Interventions:
a. Administer prescribed oral pain medication as per the surgeon’s prescription.
b. Provide non-pharmacological pain relief measures such as deep breathing exercises and relaxation techniques.
c. Regularly assess pain levels and document the effectiveness of pain relief interventions.
2. Nursing Diagnosis: Risk for Infection related to surgical incision, as evidenced by the recent surgical procedure and the risk of incision site contamination.
1. Interventions:
a. Monitor the surgical incision site for signs of infection, such as redness, swelling, or drainage.
b. Perform appropriate hand hygiene and aseptic techniques during wound care.
c. Educate the patient and family about signs and symptoms of infection and when to seek medical attention.
3. Nursing Diagnosis: Impaired Physical Mobility related to surgical procedure, as evidenced by restrictions on activity post-surgery.
1. Interventions:
a. Assist the patient with early ambulation and gradual mobilization as tolerated.
b. Provide education on turning and positioning techniques to prevent complications such as pressure ulcers.
c. Collaborate with physical therapy to develop a plan for progressive mobility.
Conclusion:
In this assignment, we analyzed two case studies and prepared Nursing SBAR communication reports for each scenario. Additionally, we developed comprehensive care plans based on patient information, including three NANDA nursing diagnoses with related interventions and patient goals. These care plans aim to provide holistic patient-centered care and optimize positive health outcomes.