Application of Theory

Case 1  

Mr. E, an 18 year old male went to the clinic due to a fever, the nurse checked his temperature and asks a few questions about how he’s feeling, his temperature was 38°C and he stated that he feels an itch in his ear and he also said the it is painful as if there is pressure in his ear and complains about a loss of hearing, the nurse checked his ear using an otoscope and noticed that dilated blood vessels are visible and the eardrum is red and bulging with visible fluid. 

    I. Assessment

        a. Subjective(symptoms)

            1. Itchy ear

            2. Pain in the ear

            3. Loss of hearing

        b. Objective(signs)

            1. High temperature

            2. Eardrums are swelling

            3. Fluid is present in the ear

    II. Diagnosis

            Acute pain related to the inflammation of the middle ear

    III. Plan

         a, Short-term Goal

            After 1 hour, the patient will feel better as evidenced by relieved or reduced pain and temperature.

        b. Long-term Goal

           After 1 week, the infection will be gone as evidenced by a normal temperature and the absence of irritation in the ear and absence of fluid.

    IV. Intervention

        1. Position the patient in the upright position or lie in an unaffected ear.  

        2. Remove fluid using cotton wool.

        3. Tell the patient not to touch the ear or use cotton buds to avoid irritation of the ear.

        4. Assess hearing ability frequently.

        5. Prescribe antibiotics for the infection. 

        6. Monitor the patient for signs of relief from pain and any side effects of medication.

    V. Evaluation

        a. Short term

           Achieved as evidenced by absence of irritability of the ear and a normal temperature.

        b. Long term

            Achieved as evidenced by absence of fluid and swelling of the eardrum.

         

Case 2 

Mrs. X, a 55-year-old female, was admitted to the hospital with a frequent productive cough. She states, "My chest hurts when I cough, and it was hard for me to sleep at night." The nurse checked her vital signs, her temperature is 38.5 °C, and she is shaking with chills. The nurse also went over her medical history and discovered that she had been diagnosed with community-acquired pneumonia and had a fever two days prior. The nurse realizes that a priority nursing diagnosis is ineffective airway clearance.

    I. Assessment

        a. Subjective(symptoms)

            1. Cough

            2. Chest pain when coughing

            3. Has a hard time sleeping at night

        b. Objective(signs)

            1. Productive cough

            2. Shaking chills

            3. High temperature

    II. Diagnosis

        Ineffective airway clearance due to community-acquired pneumonia

    III. Plan

        a. Short-term Goal

       After 5 hours, the patient will have an effective airway clearance than before, lower temperature, less to no chills, and feel less pain in the chest when coughing.

        b. Long- term Goal

       After 2 weeks or before discharge, the patient’s condition will improve; absence of fever and chills, improved cough to no cough at all, and slowly recovering from community-acquired pneumonia.

    IV. Intervention

        1. Assess the patient's breathing rate, depth, and chest movement.

        2. Elevate head of bed to 45 degrees.

        3. Assess the patient every time they cough and the chest pain, they feel.

        4. Encourage the patient to cough out the mucus.

        5. Teach the patient breathing techniques.

        6.Tell the patient to avoid too much movement for the meantime.

        7. Tell the patient to get lots of rest.

        8. Prescription of antibiotics.

    V. Evaluation

        a. Short term

            Achieved as evidence by lower temperature, felt less chills, pain in the chest when coughing lessens, better airway clearance.

        b. Long term

            To be evaluated before discharged.