Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example

Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example

In the case scenario, Nikki is an 18-year-old presenting with an Asthma medical history since she was a child. In rainy, cold, and damp weather, the patient feels tired and experiences shortness of breath with minimal exertion. She takes the puffer with minimal effect when she presents in the emergency department with a respiratory rate of 36 breaths per minute, wheezing during inhalation, and SPO2 of 89% at room air. On chest auscultation, she presents with wheezes and decreased air entry bilaterally at the base of the lungs. This personalized care plan paper will provide three nursing diagnoses for the patient, planning goals/anticipated outcomes, interventions, and evaluation of the treatment outcomes. The report will also summarize the benefits of utilizing nursing processes while highlighting the metaparadigm concepts for assessment and SMART criteria for goals.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Three Diagnoses

Following a review of the presented case study, Nikki’s medical history and presenting symptoms indicate the following symptoms;

1. Actual Diagnosis- Asthma Exacerbation

Asthma exacerbation refers to acute or sub-acute episodes of progressive worsening of asthma, such as shortness of breath, wheezing, coughing, and chest tightness. The worsening of the symptoms may be triggered by environmental factors such as cold weather or even physical exertions (Al-Shamrani et al., 2019). Nikki’s exposure to cold and damp weather led to clinical presentations, such as fatigue, wheezing, shortness of breath, and minimal relief from her inhaler, which point toward an asthma exacerbation diagnosis.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

1. Potential Diagnosis- Respiratory Infection

The patient’s symptoms may also have been triggered by respiratory infections such as bronchitis and pneumonia. Pneumonia and bronchitis cause fatigue, wheezing, shortness of breath and worsen the symptoms of asthma (Nowicki & Murray, 2020). On auscultation, Nikki also presented with decreased air entry based on the lungs bilaterally, indicating a lower respiratory tract infection.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

1. Wellness Diagnosis

Nikki’s enhanced knowledge of the management of asthma symptoms and its complications. Secondly, her willingness to seek and comply with medical treatment supports the proper use of her inhaler. The patient may have reduced knowledge of asthma management in cold and damp weather or during physical exertion, leading to exacerbation. Nikki may also have poor techniques using the inhaler, leading to minimal effect upon using it.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Planned Goals and Interventions

Priority Diagnosis: Asthma Exacerbation

The priority diagnosis for Nikki is asthma exacerbation since the patient experiences impaired gaseous exchange. The patient’s oxygen saturation level is 89%, below the normal levels (95-100%), while the respiratory rate is 36 breaths per minute, significantly higher than the normal 12-20 breaths per minute. For this reason, the patient has impaired gaseous exchange that may lead to severe complications if not addressed immediately.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Goal Statement 1: The patient’s SPO2 will increase to at least 95% within the next 24 hours

Expected Outcome: The patient will portray normal breathing patterns, demonstrate decreased wheezing and shortness of breathing

Goal Statement 2: The patient’s respiratory rate will return to normal (12-20 breaths per minute) within 24 hours.

Expected outcome: Nikki will have normal air entry at the base of both lungs

Goals Statement 3: The patient will have improved knowledge of asthma management during cold and damp weather to prevent future asthma exacerbation within the next 24 hours.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Expected outcome: The patient can use her puffer or inhaler effectively.

Interventions

As a nurse, one of the patient’s priority interventions would be administering supplemental oxygen as ordered. Nikki’s SpO2 level of 89% implies a low body oxygen saturation level that marks hypoxemia and predisposes her to hypoxia, where her body tissues may lack adequate oxygen to maintain normal homeostasis (Perrone et al., 2023). Thus, administering supplemental oxygen will improve the patient’s oxygenation, thus improving the oxygen saturation level to at least 94% to improve the patient’s state and manage complications.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

The second nursing intervention for the patient will be positioning Nikki in a high Fowler’s position. Supplemental oxygen will be vital to relieve hypoxemia but will not improve ventilation or treat the underlying causes of hypoxemia. However, positioning the patient in a high Fowler position allows gravity to pull down the diaphragm, thus increasing the volume of the thoracic cavity and allowing maximum chest expansion. Maximum chest expansion improves lung expansion and gaseous exchange/ventilation (Sonpeayung et al., 2019).(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

The third nursing intervention for the patient is administering Ventolin via a nebulizer as ordered. Also known as salbutamol, the medication is a selective β₂-adrenergic receptor agonist that aids in relieving acute episodes of bronchospasm caused by asthma (Marques & Vale, 2022). The medication is indicated for the patient for symptomatic relief and bronchospasm prevention through its potent properties of relaxing the smooth muscles of the airways.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Evaluation

The evaluation was instrumental in determining whether the stated goals and anticipated outcomes were achieved. The process was also vital to assess the success of the implemented interventions for the patient to make necessary adjustments. The evaluation was conducted by monitoring Nikki’s vital signs, assessing her breathing patterns and comfort, and examining her knowledge of managing asthma exacerbation. The set goals were achieved, while the interventions were successful based on the evaluation. By the end of 24 hours, the patient’s SPO2 was 94%, while her respiratory rate was 17 breaths per minute. The patient also portrayed improved breathing comfort marked with effortless breathing. Normal breath sounds were also heard based on both lungs, indicating improved lung expansion.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Step 2: Summary

The nursing process is a systematic and rational model of planning utilized to guide patient care that nurses must use to make a clinical judgment and perform clinical reasoning to deliver patient-centered and holistic care. The nursing process comprises primary steps that include assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Notably, nurses also use the metaparadigm concepts to guide their nursing process. The nurses also set SMART goals that promote efficiency to meet the desired treatment outcomes and deliver quality care.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Significance of Each Step of the Nursing Process

Assessment is the first step of the nursing process. It is instrumental since it allows the nurses to collect, organize, validate, and document the patient’s health by identifying potential health, psychological, physiological, emotional, and socioeconomic problems. The step allows the nurses to create a rapport with the patients while creating a basis for the subsequent steps. Secondly, diagnosis allows nurses to analyze the obtained data to establish the patients’ problems. By so doing, the nurses identify the patient’s needs. Thirdly, planning allows the nurses to set SMART goals and anticipated outcomes to guide the nursing intervention. During the implementation step, nurses implement the planned intervention to meet immediate patients’ needs to improve their health and prevent complications. In the final step, the nurses evaluate whether the nursing interventions were effective in devising potential improvements. The step ensures that patient health needs are addressed successfully.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Roles of Metaparadigm Concept

Metaparadigm concepts entail health, patient, environment, and nursing in nursing. The concepts were instrumental in this assignment, offering a holistic patient view (Deliktas et al., 2019). In this case, I could comprehend the patient’s health status as influenced by the environment and the roles or responsibilities of nursing toward promoting health and well-being. In the case study, cold and damp weather affected the patient’s health by exacerbating asthma symptoms. As a nurse, I managed the patient’s symptoms, such as shortness of breath, while monitoring affected vitals, such as respiratory rate and SPO2, to prevent complications. I also applied evidence-based nursing interventions such as supplemental oxygen therapy, patient positioning, and health promotion on asthma management and inhaler use to improve and maintain the patient’s health and well-being.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Significance of Setting SMART Criteria

The SMART criteria is an acronym for Specific, Measurable, Achievable, Relevant, and Time-bound. The criteria allowed me to set SMART goals vital to remain focused on meeting the identified patient needs. The set goals created a structure that increased my potential to achieve the patient goals and set outcomes. The criteria also ensured that my goals were realistic, clear, and measurable, thus promoting effective planning and evaluation of the implemented care plan. The goals are reachable within a specific timeframe, allowing me to track my progress, determine potential barriers, and improve or adjust the treatment plan based on the patient’s state and needs.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

Conclusion

The nursing process is a systematic and rational model of planning utilized to guide patient care that nurses must utilize to make clinical judgments and perform clinical reasoning to deliver patient-centered and holistic care. Subsequently, the metaparadigm concepts in nursing health, patient, environment, and nursing are instrumental in offering a holistic patient view, thus leading to improved patient outcomes. Setting SMART goals allows nurses to remain focused on meeting the identified patient needs, track their progress, determine potential barriers, and improve or adjust the treatment plan based on the patient’s state and needs.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)

References

Al-Shamrani, A., Al-Harbi, A. S., Bagais, K., Alenazi, A., & Alqwaiee, M. (2019). Management of asthma exacerbation in the emergency departments. International Journal of Pediatrics and Adolescent Medicine, 6(2), 61-67. (Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)https://doi.org/10.1016/j.ijpam.2019.02.001

Deliktas, A., Korukcu, O., Aydin, R., & Kabukcuoglu, K. (2019). Nursing Students’ Perceptions of Nursing Metaparadigms: A Phenomenological Study. The Journal of Nursing Research: JNR, 27(5), e45.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example) https://doi.org/10.1097/jnr.00000000000

Marques, L., & Vale, N. (2022). Salbutamol in the Management of Asthma: A Review. International journal of molecular sciences, 23(22), 14207.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example) https://doi.org/10.3390/ijms232214207

Nowicki, J., & Murray, M. T. (2020). Bronchitis and Pneumonia. Textbook of Natural Medicine, 1196–1201.e1. (Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example)https://doi.org/10.1016/B978-0-323-43044-9.00155-2

Perrone, S., Manti, S., Petrolini, C., Dell’Orto, V. G., Boscarino, G., Ceccotti, C., … & Gitto, E. (2023). Oxygen for the Newborn: Friend or Foe? Children, 10(3), 579.(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example) https://www.mdpi.com/2227-9067/10/3/579/pdf

Sonpeayung, R., Tantisuwat, A., Janwantanakul, P., & Thaveeratitham, P. (2019). Total and Compartmental Chest Wall Volumes, Lung Function, and Respiratory Muscle Strength in Individuals with Abdominal Obesity: Effects of Body Positions. Journal of Obesity, 2019, 9539846(Using Nursing Concepts and the Nursing Process to Develop a Personalized Nursing Care Plan Comprehensive Nursing Paper Example). https://doi.org/10.1155/2019/9539846