Assessment and Nursing Diagnoses for Ms. Hayes

QUESTION

Juan is Ms. Hayes’s nurse. She puts her light on and asks for something for pain; she tells Juan that the abdominal pain she has is a 9. Juan brings her morphine 4 mg and gives her the IV push (IVP) dose. He comes back 15 minutes later to evaluate the effectiveness of the pain management plan.

Ms. Hayes is calm, smiling, and reports the pain at 0. Juan examines the abdominal dressing, the IV site, and listens to Ms. Hayes lungs. He notices the crackles in the lungs and is concerned. He observes that her respiration is shallow and rapid, and he asks her to breathe deeply and notices it triggers a cough; he also sees a pain response in her expression with the cough. He realizes that she has been under anesthesia for 3 hours and has been on an operating room table, a stretcher, or in her bed for the last 24 hours. And he also appreciates the effects of incisional pain on her respirations.

Ms. Hayes complains of dyspnea, feeling cold, and coughing up green phlegm. Her pulse oximetry is 87%, respiratory rate is 30; she breathes shallowly and is using accessory muscles to breathe. Her temperature is up to 102.9 F. You auscultate her lungs and find diminished breath sounds with crackles throughout that are present in the right lung, with a clear left lung in all fields. Her respiratory status has continued to decline despite the efforts you put in place to improve it, and she has a postoperative complication of pneumonia.

1. Identify three pieces of assessment data (defining characteristics) that the nurse could use to support the actual nursing diagnosis of Acute Pain for Ms. Hayes
2. List a minimum of three actual nursing diagnostic labels (not including Acute Pain) applicable to Ms. Hayes’ current condition.
3. Write two risk nursing diagnoses for Ms. Hayes.
4. Write three nursing plans/goals for Ms. Hayes
5. Three nursing interventions
6. Evaluate

ANSWER

Assessment and Nursing Diagnoses for Ms. Hayes

Assessment Data for Acute Pain Diagnosis

Self-Reported Pain Intensity: Ms. Hayes reported her abdominal pain as a 9 on a scale of 0-10.
Pain Response: Ms. Hayes demonstrated a pain response when asked to breathe deeply, triggering a cough that caused pain.
Facial Expression: Ms. Hayes exhibited a pain response on her face when coughing due to the incisional pain.

Actual Nursing Diagnostic Labels

Impaired Gas Exchange: Evidenced by crackles in the lungs, decreased breath sounds, shallow and rapid respirations, accessory muscle use, and oxygen saturation of 87%.
Ineffective Airway Clearance: Evidenced by cough, green phlegm, diminished breath sounds with crackles in the right lung, and the use of accessory muscles.
Hyperthermia:Evidenced by a temperature of 102.9 F, which is indicative of an elevated body temperature.

Risk Nursing Diagnoses

Risk for Infection: Due to postoperative pneumonia, evidenced by cough, green phlegm, and elevated temperature.
Risk for Decreased Cardiac Output: Due to impaired gas exchange, evidenced by crackles, decreased breath sounds, and shallow respirations.

Nursing Plans/Goals

Goal: Improve Gas Exchange: Monitor oxygen saturation, administer supplemental oxygen as prescribed, encourage deep breathing exercises, and administer prescribed respiratory treatments.
Goal: Effective Airway Clearance: Administer nebulized treatments as ordered, encourage productive coughing and deep breathing, and assess the effectiveness of interventions.
Goal: Manage Hyperthermia: Administer antipyretics as prescribed, provide cooling measures (e.g., cool compresses), and monitor temperature regularly.

Nursing Interventions

Administer Pain Management: Administer analgesics as ordered, assess pain levels regularly, and provide comfort measures.
Initiate Pneumonia Protocol: Administer prescribed antibiotics, encourage deep breathing and coughing exercises, and monitor respiratory status closely.
Maintain Hydration: Administer intravenous fluids as prescribed, monitor fluid intake and output, and ensure Ms. Hayes is well-hydrated.

Evaluation

Despite the nursing interventions put in place, Ms. Hayes’ respiratory status continued to decline, leading to the diagnosis of postoperative pneumonia. The goals related to improving gas exchange and effective airway clearance were not fully achieved due to the worsening symptoms. The goal of managing hyperthermia was partially achieved, as her temperature remained elevated despite antipyretic administration. Reassessment and potential adjustments in interventions are required to address her deteriorating condition effectively.