Client Assessment

Client: 76 year old female

Assessment/Data Collection:

Subjective:

“I can’t wait to go home to my husband tomorrow”

“I am able to take care of myself except when lifting my arms over my head”

Objective:

Talkative

Active in therapy

Agreeable to all assistive devices and training provided by therapists at HealthSouth

SOB upon exertion

Productive Cough

Nursing Diagnosis:

Knowledge Deficit r/t altered health maintenance AEB trouble moving air into and out of lungs s/p open heart surgery.

Client Assets and Limitations:

Assets Limitations

Patient has no hearing, vision or cognitive impairmentsCommunicates wellWilling to learn and do things for herselfAble to transfer from wheelchair to bed/toilet without assistanceContinent of urine/fecesHas husband and daughter at home to assist with continuation of therapy

SOB upon exertionPain when lifting arms Incisional pain from open heart surgeryWeakness s/p coronary graftHistory of 50+ years cigarette use

Goal: Patient will understand importance of using Incentive spirometer every 2 hours while awake as ordered by physician.

Objective:Cognitive: Teach patient of benefits of Incentive spirometerCognitive: Teach patient that the reason for incentive spirometry is to help him fully inflate his lungsPsychomotor: Patient will report number of times used daily and mark progress with indicatorPsychomotor: Patient will demonstrate knowledge of COPD process, meds, therapy and follow up care.Affective: Patient agrees to use every 2 hours while awakeAffective: Patient agrees to report signs of respiratory compromiseContent:Teaching patient to exhale completely with her mouth off the spirometer mouthpiece. Then she should seal her lips tightly around the mouthpiece, breathe in as slowly and deeply as possible through her mouth, and note the highest level the indicator reaches. When she can't inhale anymore, she should hold her breath for at least 3 seconds then exhale normally. Encourage her to try to reach prescribed goal as defined by her physician.

Teaching patient of COPD process and how incentive spirometry combined with exercise, therapy, and compliance to medications allows for greater rehabilitation potential.

Teach patient which signs and symptoms of respiratory compromise that should be reported to healthcare staff immediately.Planned teaching strategies and teaching/learning Activities:Nurse will instruct by verbalizing the importance of using incentive spirometer as prescribed by physician, which is currently every 2 hours while awake.

Nurse will give patient information about COPD and how the incentive spirometer can help improve the function of her lungs.

Nurse will provide rest periods for comfort.

Nurse will provide written easy to understand information on proper use of incentive spirometer.

Nurse will provide same teaching information and material to include patients’ family who will be overseeing her care/safety when she leaves HealthSouth. Assistance of the family may have a positive effect on patients’ outcome.

Nurse will provide written instructions on which signs and symptoms of respiratory compromise that need to be reported immediately.Time Frame:30-45 minutesEvaluation Method:Goal Met. During my shift patient demonstrated and properly used incentive spirometer every 2 hours while awake and marked progress with the indicator so that she could report it to her LPN. PulsOx was @ 92% before using spirometer then at 96% after use.