Focused exam cough Care Plan

Nursing Diagnosis
3.5 out of 3.5

Nursing Diagnoses: Definitions & Classifications 2018-2020 © NANDA-International, 2017 used by arrangement with Thieme Medical Publishers, Inc., a division of the Thieme Group. All rights reserved. Authorized translation from the English language edition published by Thieme Medical Publishers Inc. No part of this material may be reproduced in any form without the written permission of the agent of the copyright holder, NANDA-International. Direct inquiries to [email protected]. (http://www.nanda.org/).

Status:

Student Response Model Answer Explanation Points Earned
is at risk for is at risk for The correct status for the nursing diagnosis is “is at risk for,” because Danny’s most pressing vulnerability is to an infection that he has not yet but could develop. 0.5 out of 0.5

Diagnosis

Student Response Model Answer Explanation Points Earned
infection infection While a cough can be unpleasant, the most alarming thing it indicates about Danny’s health is that he is at risk for an infection. 0.5 out of 0.5

Etiologies

Student Response Model Answer Explanation Points Earned
rare hand washing rare hand washing Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
played w/ sick peer played w/ sick peer Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
secondhand smoke secondhand smoke Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke Focused exam cough care plan. 0.5 out of 0.5
touches face often touches face often Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5

Signs & Symptoms

Student Response Model Answer Explanation Points Earned
N/A N/A Because the infection that Danny may develop hasn’t happened yet, he is not currently presenting with any signs or symptoms, so the correct answer here is “N/A.” 0.5 out of 0.5

Self Assessment

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Why would a nursing diagnosis of a cough be incorrect, compared to a risk for infection? Consider the difference between nursing and medical diagnoses. A persistent and unpleasant cough could be a symptom of something more severe, and the immune system is at risk of infection. The effective nursing care to prioritize is educating a patient on how to avoid more severe outcomes. While a cough can be unpleasant and frequent, it is actually a symptom of something more alarming: the immune system being at risk for an infection. The most effective nursing care you should prioritize is to educate your patient on avoiding this more serious outcome. Your nursing diagnosis should always take into account what condition is most serious, receiving the greatest benefit from your help. This diagnosis may not be the most obvious physical symptom to you or your patient, so always consider what is jeopardizing a patient’s health the most.

Planning

4 out of 4

Focused Exam: Cough – Danny Rivera Shadow health Objective; Subjective Data

Short-Term Goal

Student Response Model Answer Explanation Points Earned
To have the patient and his guardian verbalize and agree to their instructions on how to avoid infection & practice respiratory hygiene, by end of the healthcare visit. To have the patient and his guardian verbalize and agree to their instructions on how to avoid infection & practice respiratory hygiene, by end of the healthcare visit. A risk-based diagnosis does not require medical interventions as the problem is hypothetical; the goal that does suit the diagnosis involves teaching the patient and his guardian about risk-reduction methods. 0.5 out of 0.5

Interventions

Student Response Model Answer Explanation Points Earned
Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct family and patient that patient should increase fluid intake Instruct family and patient that patient should increase fluid intake Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens) Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens) Focused exam cough care plan Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick Focused exam cough care plan Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5

Instruct patient to avoid touching fingers to eyes, nose, or mouth Instruct patient to avoid touching fingers to eyes, nose, or mouth Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5

Instruct patient to cough into tissue, or sleeve if tissue is unavailable Instruct patient to cough into tissue, or sleeve if tissue is unavailable Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5

Intervention Rationale

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal. The intervention will teach the patient and guardian various ways to keep their hands and lungs clean, which helps eliminate pathogens and reduce the risk for infection. These interventions will teach Danny and his guardian how to keep their hands and lungs clean in a variety of ways, so that Danny’s risk for infection is reduced as pathogens are eliminated. Infection can be caused by multiple culprits, so it’s important that your patient teaching covers a thorough and specific array of anti-infection habits. Focused exam cough care plan

Data Collections

Student Response Model Answer Explanation Points Earned
Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene Focused exam cough care plan It is important that your patient and his guardian agree to their instructions, as changing lifestyle habits can be intimidating but necessary for the patient’s health. Having Danny and his father verbalize back their instructions also assures they remember and understand the details. 0.5 out of 0.5

Discussion Of Care

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt Student Response Model Answer Explanation

Explain the rationale behind your nursing diagnosis. Danny, we want to make sure you don’t develop an infection and become more sick by taking you through the different that can prevent that and the focus will be on your risk factors. Some of your risk factors include you being close to a sick friend, exposure to cigar smoke, having touches your face with uncleaned fingers. They may sound a lot but by working together and mitigating your risk factors can be easy and effective Danny, given that you aren’t feeling well, we want to make sure you don’t develop an infection, which for you just means getting even sicker. We’re going to talk about the ways we can work to prevent that, especially focusing on your risk factors, which are just things that give you a bigger chance of being sick. Some of your risk factors are that you were near a sick friend, have been exposed to cigar smoke, could stand to wash your hands more, and have touched your face with your fingers. I know that sounds like a lot, but if we work together, reducing your risk factors for infection can be easy and effective. A patient should understand their nursing diagnosis and the rationale behind it to increase their sense of involvement and to identify areas for future improvement. Explain your goal for Danny and the interventions and data collections through which you will achieve it. To make sure you don’t become sicker, I will talk to you and your father and what must e done. The three of us will collaborate and agree to your health goals. Then both of you will repeat what you have learnt to be sure you have understood all which should be done. Let’s talk about how we’re going to help you not get sicker! So, I’m going to have a conversation with you and your father about things to do to ensure your health. You, he, and I will work together to discuss, and then have you agree to your goals. Then I’m going to have you and your father repeat what you’ve learned, so we can make extra sure you’ve got it down pat! You should communicate the Care Plan to the patient, allowing them to exercise involvement and agency in their own healthcare. Explicitly ask for Danny’s consent to the Care Plan. Does the plan sound good to you? Does this plan I just talked about sound good to you? A patient must consent to all interventions in their Care Plan. Disagreements are opportunities to provide further patient education and to consider alternative options. Inform Danny you will now begin educating him and will then call to educate his guardian. If you don’t have any other question, we can start our discussion. Danny, if you don’t have any other questions, we can start our discussion now! It’s time to begin your education interventions, so let your patient know!

Intervention & Evaluation

2.5 out of 2.5

Student Response Model Answer Explanation Points Earned
Partially Partially While Danny correctly verbalizes and agrees to his instructions for reducing infection risks, his father only agrees to some of his instructions, expressing apprehension toward not smoking inside the house. Your goal has been partially achieved. 2.5 out of 2.5
Intervention & Evaluation Rationale

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Did you achieve your goal for your patient and his guardian by the end of the visit, getting each of them to agree to and verbalize your instructions for avoiding infection and practicing respiratory hygiene? Danny agrees and has verbalized a full and correct understanding on what to do. However, his father is reluctant on reducing his smoking inside the house as one of the interventions was to keep the house free from smoke to reduce the risk of infection. Thus, this aspect is yet to be achieved. Nevertheless, Danny and his father verbally agree to all other instructions, so the overall goal has been partially achieved. While Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside the house. One of his instructions was to keep the house smoke-free in order to reduce Danny’s risk of infection, so this aspect of your goal has not been achieved. However, both parties verbally agree to most of their other instructions, so your overall goal has been partially achieved. Even with progress being made in almost all aspects of your patient teaching, you must adhere to your goal and consider your work incomplete if certain agreements have not been reached.

3.5 out of 3.5

 Self Assessment

 Planning

 Discussion Of Care

 Intervention & Evaluation

 Intervention & Evaluation Rationale