Orem’s Self Care Deficit Theory Clinical Care Plan

Written by: Guiomar Goransson Nov.2003

Orem’s Self Care Deficit Theory Clinical Care Plan

Patient Initials: LG Age: 79 Gender: Caucasian Female

LG was admitted to Flower Hospital on October 12, 2003 with a diagnosis of pneumonia, severe shortness of breath, vomiting, diahhrea, lethargy, disorientation, semi-consciousness. She was brought in by her husband who said that LG was having a hard time breathing and was drifting in and out of consciousness.

Presenting Diagnosis: Community Aquired Pneumonia

Surgical Procedures: none

Chronic Conditions:

Hypertension

Definition of Presenting Diagnosis: Community Aquired Pneumonia

Pneumonia is an inflammation of the lungs caused by a bacterial, viral, or fungal infection. Streptococcus pneumoniae is the most common cause of CAP in all age groups.

Pathophysiology of Presenting Diagnosis:

Hypertrophy of mucous membrane lining of lung, resulting in hypersecretion.
Bronchospasm from increased secretions.
Increased capillary permeability resulting in excess fluid in interstitial spaces.
Decreased surface area for gas exchange.
Inflammation of pleurae.
Hypoventilation, hypoxia.
Respiratory acidosis (in presence of underlying disease).
Bacteremia.

Clinical Manifestations:

Increased sputum production and cough. Complications of persistent coughing can include vomiting and fainting due to hypertrophy of mucous membrane lining of lung, resulting in hypersecretion.
Pluera maintains close approximation of lungs and chest wall; minimizes friction during lung expansion and contraction. When inflammation of pleurae occurs, patient can experience chest pain, especially on inspiration, pleural effusion, dullness on percussion, decreased breath sounds, decreased vocal fremitus.
Altered mental status related to hypoxia.
Elevated white blood cell count: leukocytes (15,000 to 25,000/mm)
Neutrophilia, where neutrophils (circulating white blood cells essential for phagocytosis of bacteria) are elevated.
Respiratory acidosis, a decrease in the pH and increase in carbon dioxide resulting from alveolar hypoventilation

Usual Collaborative Management:

· Hospitalization for those age 50 or over.

· Initial treatment is with a broad spectrum antimicrobal.

· Parental antibiotics for 2-3 days often improves patient’s condition sufficiently enough that oral antibiotics can be substituted for treatment continued on an outpatient basis.

· Respiratory therapy. Oxygen is titrated to maintain SP02.

· Turning, coughing and deep breathing performed regularly

· High-calorie, high-protein diet with frequent small feedings is usually prescribed

· Patient should be on bedrest but may be out of bed to use toilet or commode chair.

· Early mobilization and activity.

· X-ray

· Thoracentesis- insertion of needle into pleural space to remove fluid.

Basic Conditioning Factors

Developmental State:

Theorist: Erikson

References: DeLaune pg. 310

Generativity vs Stagnation, Generativity
Age 45+
View one’s life as meaningful and fulfilling.
Explore positive aspects of one’s life.
Review contributions made by the individual.
LG is establishing a marriage with her second husband.
States she is satisfied with how she raised her children.
Actively involved with two sons and 8 grandchildren
Stated very happy with second marriage and retirement lifestyle.
Stated enjoyed her career as bus driver.
Stated enjoys now enjoys solely being homemaker.

Health State:

O T 99.4 P 96 R 24 B/P 132/84
O Pleasant and cooperative with medical regimes
O Has become A0x3 since during hospital stay.
O Ambulates independently.
O Prior illnesses include: edema of hands and feet, hypertension.
O Past surgeries include: tonsillectomy, hysterectomy, cystocele and rectorcele repair, appendectomy.
O Allergic to penicillin, Neospirin.
O All lab results in normal range.

Stated “condition has greatly improved since being hospitalized”, but wants to regain complete health and go home.

Stated “always been healthy without any real problems”.

Never smoked.
Doesn’t drink alcoholic beverages
Performs self-breast exam monthly
Very motivated to recover, stated goal is “to go home”

Health Care System:

Visits family physician regularly.
Interacts amiably with nurses.
Interested in her treatment, asks questions.
Interested in learning/knowing her condition.
Understands need to eat healthy foods for good nutrition and recovery.
Performs self-breast exams, had a mammogram and has annual pap tests.
Advance directive on file

Available Resources:

LG and husband receive pensions and social security to support themselves.
Health Insurance adequate to cover health requirements.
Husband and sons are supportive, sons offer to help with household chores.
Niece lives close by, very supportive.
Sisters do not live in area, but talk by phone often.

Sociocultural/Spiritual/Family System:

States a belief in God
Raised in Pentecostal faith
Cultural background, midwestern.
Caucasian
Widowed, remarried
Two sons, ages 50, 52
LG was middle child
Mother/deceased/thyroid
Father/deceased/cancer
#1Sister/cancer
#2Sister/diabetic
Family Developmental Stage, is Married couple due to recent marriage; and Aging Family due to adapting to retirement and aging.
No major recent events.

Patterns of Living:

Homemaker, does not work outside the home.

Late sleeper, likes to sleep in in morning.
Night person, likes to stay up late.
Rises around 10 am, reads the paper
Does not eat breakfast.

Bathes in morning.
Does housework.
Eats lunch.
Drives her own car.
Receives visits from her children and grandchildren several times a week.
Does laundry.
Prepares dinner, LG and husband eat dinner together.
Sometimes watches TV in evening.
Hobby is knitting, sewing and making things for home.
Enjoys playing cards, working crossword puzzles.

Environment:

Lives in one story, ranch style home, with two bedrooms.
One step entrance.
Lives with husband.
Bed, bath, laundry, all living quarters on one floor.
Bath with tub.
LG does not allow anyone to smoke in house.
Feels neighborhood is safe.
Safety concerns, falls, ability to get around to take care of self .

Relevant Life Experiences:

Loss of father to cancer
High School graduate
Childbirth, two children , one stillbirth.
Worked as bus driver, part and full time for approximately 45 years.
Widowed after 50 years of marriage.
Second marriage, married for three years.
Stressors include concern over grandchild and one son and this current illness.

Universal Self Care Requisites:

1. Maintenance of Air/Respiratory:

· O Respiratory protocol for hypoxia

· SP02 92% Pulse Ox

· O Intermittant cough hoarseness, productive; sputum thick and yellow.

· OThorax shape 2 x 1, symmetrical

· O Some shortness of breath, esp. after extended talking or light activity (eg. walking to bathroom, brushing hair).

· O Respiratory excursion, slightly diminished on right.

· O Posterior lung sounds: quiet.

· O Anterior lung sounds: lower right quadrant crackling.

· O Lateral lung sounds: lower right side sounds crackly.

· O Capillary refill sluggish, 4 seconds

· O Decreased inspiration. Inspiration unequal to expiration.

· O Use of accessory muscles while breathing.

· O Tactile fremitus, diminished.

· O Skin is cool and moist with light perspiration.

· Complains of occasionally breathing hard, shortness of breath, lethargy.

· No chest pain

· Rarely gets colds, none last year.

· Allergies include penicillin, Neosporin.

· Non-smoker

2. Maintenance of Air/Cardiovascular:

· O Apical, radial pulse equal, +3

· O Carotid arteries +3, no bruit

· O Jugular vein, no distension

· O Peripheral pulses, +3

· O P 96 R 24

· No family history of CAD

3. Maintenance of Sufficient Food/Water:

· O Clear liquid diet

· O I&O being measured.

· O I = 500mL O = 250mL

· O Consumes 3 clear liquid meals per day while in hospital.

· O Takes daily multi vitamin

· O Wears full dentures

· O Height 5 feet 4 inches Admission Weight n/a Current Weight 126

· O Metropolitan Chart Weight 114-152

· O Skin is cool and moist with light perspiration.

· States “no problems wanting to eat usually, but haven’t been hungry since I got sick” .

· Likes vegetables, states “tries to eat healthy” .

· No problems chewing .

· Able to feed self.

· Drinks 4-5 glasses of water per day

· Has reduced coffee intake to one-two cups decaffeinated daily.

· Drinks fruit juice, one glass for breakfast and one midday.

· Drinks carbonated cola beverages occasionally, approximately one-two cans per week.

· Does not consume alcoholic beverages..

· Does not drink milk, except with cereal.

4. Maintenance of Balance Activity/Rest:

O Able to bathe, dress, feed self, however, tires after these activities.
O Full ROM, no limitations.
O Ambulates independently, however, experiences some shortness of breath, esp. after extended talking or light activity (eg. walking to bathroom, brushing hair).
O No edema or deformities.
Grooms self every morning, applies make-up.
States, “I’d like to walk up and down the hospital hallway but I’m too tired.”

Homemaker
Number one goal is “to get back my pep”.

5. Prevention of Hazards:

O Medical diagnosis, Pneumonia
O Allergy to penicillin, Neosporin.
O Fall precautions.
Family is aware of diagnosis
Primary concern is getting health back.
No OTC meds.
See med list for medications
Feels safe in hospital and at home
Wears prescription trifocal glasses.
No restraints used/necessary

6. Normalcy:

O PERRLA 4
O Alert, oriented x 3
O Speech communication is clear and understandable
O No seizures
O Fall precautions.
No problems with speech, taste, touch
States “unable to smell as well as used to”
Wears prescription bifocal glasses.
States hearing has diminished slightly in last year.
High school graduate.
No problems with memory.
Describes usual mood as good.
Stress from concern over grandchild and one son and this current illness..
Deals with other stress by talking with husband.
Sees self as person most responsible for health.
Well adjusted, not emotionally upset.

7. Provision of Care with Elimination, Bowel/Bladder/Skin

O No sores or lesions, no ecchymoses.
O Mucossa moist, no coating of tongue.
O No abdominal tenderness, pain or cramping.
O Bowel sounds active all four quadrants.
O Abdomen flat, soft, no distention, no masses or bulges.
O Girth measures thirty-four inches.
O Nails pink, short, clean and manicured, no clubbing or ridging, sluggish capillary refill.
O Hair grey, thinn ing, fine texture .
O I&O being measured.
O Continent of bowels/bladder.
O Skin is cool and moist with light perspiration.
BM 1x per day in morning of soft, formed brown stool
No problem with constipation, diarrhea or gas

No hemorrhoids
No concerns, states “bowels work fine”
Urinates 6-8 times per day
No problems with urination, no burning, no pain

8. Maintenance of Solitude/Social Interaction:

States most important people in life, husband, sons and grandchildren.
Lives with husband.
Has time during day for self
Enjoys reading home magazines and crafting books.
Enjoys playing cards with others and solitaire by self.
Has two close female friends.
Has photos in hospital room of sons and grandchildren.
Flowers/plants/cards in room from friends and family .

Theoretic Self Care Demand:

LG needs to achieve and maintain adequate ventilation.
LG needs to manifest a patent airway.
LG needs to begin eating solid foods as soon as possible.
LG needs to increase activity to best of ability.

Strengths:

LG can bathe, dress, feed self.
LG stand and walk by herself.
LG is motivated to gain health.
LG is aware of need to eat healthy, nutritious meals.
LG has a supportive family.
LG seeks social interaction.
LG is Aox3.

Limitations:

LG is weak, lethargic.
LG occasionally experiences shortness of breath.
LG is experiencing loss of appetite.
LG has stressors in her life.

Nursing Diagnoses:

Gas exchange impairment R/T altered oxygen supply, AEB:

Dyspnea
Tachycardia
Diaphoresis

Tissue perfusion alteration (cardiopulmonary) R/T decreased cellular exchange, AEB:

Capillary refill time greater than 3 seconds.
Use of accessory muscles.

Airway clearance, ineffective R/T presence of tracheobronchial obstruction or secretions, AEB:

Adventitious breath sounds, such as crackles.
Diminished breath sounds
Sputum

Breathing pattern, ineffective R/T decreased energy or fatigue, AEB:

Decreased inspiratory or expiratory pressure.
Prolonged expiration phase.
Shortness of breath.
Accessory muscle use.
Altered chest excursion

Activity intolerance R/T imbalance between oxygen supply and demand, AEB:

Verbal report of fatigue or weakness.
Exertional discomfort or dyspnea.

Definition of Problem:

LG is experiencing shortness of breath, dyspnea, fatigue and lethargy due to interference in cellular respiration resulting from inadequate exhange or transport of oxygen and carbon dioxide.

Defining Characteristics:

LG exhibits dyspnea
LG exhibits tachycardia

LG exhibits diaphoresis

Related Factors:

Respiratory response to pneumonia.
Altered oxygen supply.
Alveolar-capillary membrane changes.

Patient Diagnostic Statement:

Pneumonia

Nursing System:

Partially compensatory
LG is able to perform some but not all of her self care activities

Complete Nursing Diagnosis I:

Gas Exchange impairment related to altered oxygen supply, as evidenced by diaphoresis, dyspnea, tachycardia and abnormal respiratory rate, rhythm and depth.

______________________

Desired Patient Outcome and Time Frame:

LG will state express feeling of comfort in maintaining air exchange by 10-16-03.

Intervention:

Assess and record pulmonary status every 4 hours or more frequently if patient’s condition is unstable.

Rationale:

Poor pulmonary status may result in hypoxemia

______________________

Desired Patient Outcome and Time Frame:

LG will have normal breath sounds by 10/17/03.

Intervention:

LG will change positions at least every 2 hours

Rationale:

Changing position at least every 2 hours to help mobilize secretions and allow aeration of all lung fields.

______________________

Desired Patient Outcome and Time Frame:

LG will cough effectively by 10-16-03

Intervention:

LG will receive respiratory therapy
Perform bronchial hygiene as ordered, including coughing.

Rationale:

Promotes drainage and keeps airway clear.

______________________

Complete Nursing Diagnosis I Evaluations:

______________________

10-16-02, LG demonstrates ability to produce cough and sputum.
10-16-02, LG expresses feeling of well-being.

Modification:

Continue interventions and re-evaluate in 3 days.

______________________

Complete Nursing Diagnosis II:

Tissue perfusion alteration (cardiopulmonary) R/T decreased cellular exchange, as evidenced by, capillary refill time greater than 3 seconds and use of accessory muscles.

______________________

Desired Patient Outcome and Time Frame:

LG’s heart rate will remain within prescribed limits while she carries out activities of daily living by10-17-03

Intervention:

Encourage frequent rest periods

Rationale:

Frequent rest periods conserves energy and maximizes tissue perfusion.

______________________

Desired Patient Outcome and Time Frame:

LG’s skin will remain warm and dry.

Intervention:

Monitor skin color and temperature every 2 hours. Assess for signs of skin breakdown.

Rationale:

Cool, blanched, mottled skin and cyanosis may indicate decreased tissue perfusion.

______________________

Complete Nursing Diagnosis II Evaluations:

10-17-03 LG’s heart rate remained stable at 72 bpm.
10/17-03 LG’s skin color pink and warm to touch. Skin temperature bilaterally is equal.

______________________

Modification:

Continue interventions and re-evaluate in 3 days.

Teaching:

Teaching: Inform patient about proper use of medications and possible adverse reactions.

Rationale: Effective teaching encourages patient to take active role in health maintenance.
Teaching Strategy: LG will be shown flash cards which briefly state the name and purpose of each of her medications. Later, she will be asked to match the card with drug name to the drug purpose.
Expected Outcomes & Time Frame: LG will verbally explain to nurse the name and use of each drug she is prescribed by discharge.

Evaluation/Modification: 10/16/03. LG has all drugs and purposes of each memorized and has verbally explained to nurse. Modification of this plan will include addition of side effects to match with each drug and purpose. LG will be able to state verbally the side effects of each drug by discharge.

Teaching: pursed lip breathing, and abdominal breathing

Rationale: These measures allow patient to participate in maintaining health status and improve ventilation.
Teaching Strategy: LG will have demonstrated for her by nurse and RT techniques of pursed lip breathing and abdominal breathing.
Expected Outcomes & Time Frame: LG will correctly return demonstration by discharge.
Evaluation/Modification: 10/16/03. LG can correctly demonstrate these breathing techniques to nurse. Modification of this plan will be to show LG encouragement to continue practicing these breathing techniques so that she is comfortable with them by discharge.

MEDICATIONS: