Wallpaper of 911 Carrera 4

Black ops 2 gameplay

Care plan (NKA)

STUDENT’S NAME______________________________________________________

DATES OF CARE      ______________________________________________________

UNIT ASSIGNMENT_____________________________________________________

PATIENT’S INITIALS__WS______________SEX___________________AGE________

OCCUPATION_______________________ADMISSION DATE_________________

SURGERY DATE____n/a____________________________________________________

ALLERGIES_____NKA_______________________________________________________

I.       MEDICAL DIAGNOSIS:          

-           Chronic obstructive pulmonary disease (COPD) is the overall term for a group of chronic lung conditions that obstruct the airways in your lungs. COPD usually refers to obstruction caused by chronic bronchitis and emphysema, but it can also refer to damage caused by asthmatic bronchitis. In all forms of COPD, there's a blockage within the tubes and air sacs that make up your lungs, which hinders your ability to exhale. And, when you can't properly exhale, air gets trapped in your lungs and makes it difficult for you to breathe in normally. COPD is very common. It's a major cause of death and illness worldwide, and it's the fourth-leading cause of death in the United States. In the majority of cases, COPD is caused by long-term smoking and could be prevented by not smoking or quitting smoking. However, once symptoms begin, the damage to your lungs can't be reversed, and there's no cure. Treatments for COPD focus primarily on controlling symptoms and preventing further damage. Initially, COPD is often silent. Signs and symptoms may not appear until there's significant lung damage, but once symptoms begin, they typically worsen over time. COPD symptoms may include:

§  Persistent cough

§  Increased mucus production

§  Shortness of breath, especially during physical activities

§  Wheezing

§  Chest tightness

§  Frequent respiratory infections

         (http://www.mayoclinic.com/health/copd/DS00916, retrieved 2-18-2009)

  

II.      SECONDARY DIAGNOSIS:

-        Chronic bronchitis is an inflammation of the main air passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs and shortness of breath. In chronic bronchitis, there is excessive bronchial mucus with a productive cough for three months or more over two consecutive years without any other disease that could account for these symptoms. In the early stages of chronic bronchitis, a cough usually occurs in the morning. As the disease progresses, coughing persists throughout the day. This chronic cough is commonly referred to as "smoker's cough." Also In the early stages of chronic bronchitis, only the larger airways are affected, but eventually all airways are involved. Over time the patient experiences abnormal ventilation-perfusion: insufficient oxygenation of blood (hypoxemia), labored breathing (hypoventilation) and right-sided heart failure (cor pulmonale). Compared with acute bronchitis, which may respond quickly to medications, such as antibiotics, chronic bronchitis can be difficult to treat because many patients with chronic bronchitis are susceptible to recurring bacterial infections. Excessive mucous production in the lungs provides a good environment for infection, which also causes inflammation and swelling of the bronchial tubes and a reduction in the amount of airflow in and out of the lungs. In the later stages of chronic bronchitis, the patient cannot clear this thick, tenacious mucus, which then causes damage to the hair-like structures (cilia) that help sweep away fluids and/or particles in the lungs. This in turn impairs the lung's defense against air-borne irritants. Cigarette smoking is the most common cause of chronic bronchitis. People who have been exposed for a long time to irritants, like chemical fumes, dust and other noxious substances, can also get chronic bronchitis. As chronic bronchitis often coincides with emphysema, it is frequently difficult for a physician to distinguish between the two. Chronic bronchitis also can have an asthmatic component. Lying down at night can worsen the condition, so some people with advanced chronic bronchitis must sleep sitting up. In late, severe stages people who often have emphysema as well, are called "blue bloaters" because lack of oxygen causes the skin to have a blue cast (cyanosis) and because the body is swollen from fluid accumulation caused by congestive heart failure. There is no cure for chronic bronchitis. Treatment is aimed at relieving symptoms and preventing complications. (http://www.copd-international.com/bronchitis.htm, retrieved 2-18-2009)

-       Pneumonia is an infection or inflammation of the lungs. It can be in just one part of the lungs, or it can involve many parts. Pneumonia is caused by bacteria, viruses, fungi, and other microorganisms. The severity of pneumonia depends on which organism is causing the infection. Viral pneumonias are usually not very serious, but they can be life-threatening in very old and very young patients, and in people whose immune systems are weak.  (http://www.emedicinehealth.com/viral_pneumonia/article_em.htm, retrieved 2-18-2009)

III.           HISTORY LEADING TO ADMISSION: Shortness of breath and pain in the left flank area.

         IV.    THINGS I HAVE TO DO TODAY:

Learning Goal                                                                                                

- Learn how to treat a client with COPD.      

Approach

- Review the disease the night before and watch the nurse closely, also be in the room when the physicians round.

______________________________________________________________________________

V.      LABORATORY TESTS:

Test                             Norms                         Results                        Nursing Implications

SEE ATTACHED

______________________________________________________________________________

VI.     TREATMENTS (i.e., P.T., R.T., dressing change):

Treatment                              

PT eval and treat                                Both being done to assess the clients level of functioning with and without oxygen.

OT eval and treat

RT = Albuterol and Atrovent nebulizers Q6 and PRN

RT = 6 minute walk with pulse oximetry for home o2 eval.

VII.    DIAGNOSTIC STUDIES:

-        CXR: LLL infiltrate (indicative of COPD)

-        CT Chest: BL infiltrates (Indicative of COPD)

-        Lower extremity Doppler: negative for DVT

-        2D Echocardiogram: 55-60% EF

VIII.   DIET: Cardiac Stage 3                          RESTRICTIONS: low salt and cholesterol

            A.         Reason why on this diet. History of HTN and hyperlipidemia

IX.        Surgery: Does not apply

X.         CLIENT PROBLEMS/NURSING INTERVENTIONS:

SEE ATTACHED CARE PLAN

MEDICATIONS

MEDICINE (Brand & Generic) Route, Dose, and Times	CLASSIFICATION	ACTION	REASON FOR GIVING	SIDE EFFECTS	NURSING INTERVENTION
Heparin 5000u = 1ml = inj subcut Q8 @0600	Anticoagulant, antithrombotic	Prevention of thrombus formation and extension of existing thrombi	DVT prophylaxis d/t patient not getting up out of bed and ambulating frequently	Hemorrhage, localized pain and redness in injection site, thrombocytopenia (low platelets).	Assess platelet and Hematocrit levels. Protect from injury. Check for bleeding (stool, urine). Protect patient from injury. Assess injection site.
Tylenol (acetaminophen) 650 mg = 2 tabs= PO Q6 PRN pain or fever	Antipyretic, analgesic	Inhibits the synthesis of prostaglandins that cause the transmission of pain to the CNS and reduces fever.	As needed for mild to moderate pain and fever.	Hepatic failure, hepatotoxicity (overdose), may increase the risk of bleeding of taking warfarin also, rash, urticaria	Maximum daily limit is 4 grams. Inform client not to drink alcohol while taking acetaminophen. Assess pain using COLDSPA. Notify MD of fever. Check ALT and AST.
Tessalon Pearls (benzonate) 100mg = 1 cap PO TID @ 2200	Anti-tussive, Non opioid	Anesthetizes cough or stretch receptors in vagal nerve afferent fibers found in lungs, pleura, and respiratory passages.	Cough	Headache, mild dizziness, sedation, burning eyes, nasal congestion, constipation, stomach upset, nausea, pruritis, skin eruptions, chest numbness, chilly sensation, hypersensitivity reaction.	Change positions slowly, assess for bowel sounds and ask about BM, assess lung sounds, assess respirations, adives patient to avoid irritants such as smoking, encourage high fowlers position
Voltaren (diclofenac) 75mg = 1 tab PO BIDBS @ 0800 w/meal	NSAID, Nonopioid analgesic	Inhibits prostaglandin synthesis, anti inflammatory	Decrease inflammation in the respiratory system	Dizziness, headache, drowsiness, tachycardia, HTN, hypotension, tinnitus, muscle weakness, N&V, flatulence, cramps, dry mouth, GI bleed, dysuria, UTI, epistaxis, bruising	Change positions slowly, instruct patient not to operate machinery while taking medication, assess stool for heme or tarry blackness, check CBC
Mucinex (guaifenesin) 600mg = 1 tab PO daily @1800	Expectorant	Increase the volume and reduces the viscosity of secretions in the trachea and bronchi to facilitate secretion removal	Productive and nonproductive cough	Drowsiness, headache, dizziness, N&V	Change positions slowly, increase fluid intake, do not break, crush, or chew tablet, evaluate cough and sputum and assess lung sounds
Levaquin (levoflaxin) 500mg = 1 tab PO q24h @1800	antiinfective	Interferes with conversion of DNA in bacteria	bronchitis	Headache, dizziness, insomnia, anxiety, seizures, encephalopathy, chest pain, palpitations, vasodilation, dry mouth, visual impairment, N&V, flatulence, abdominal pain, vaginitis, crystalluria, hemolytic anemia, rash, pruritis, hypoglycemia,	Change positions slowly, check CBC, assess WBC count, assess bowel pattern daily, assess cogniscence, check BP q4, encourage fluids, check blood sugar, check sodium level
Robaxin (methocarbamol) 500mg = 2 tabs= 1000mg PO qid @0900	Muscle relaxant	Depresses multisynaptic pathways in the spinal cord, causing skeletal muscle relaxation	bronchospasm	Dizziness, weakness, drowsiness, depression, seizure, postural hypotension, blurred vision, N&V, discolored urine, rash, pruritis, fever, hepatitis	Change position slowly, check sodium level, instruct patient not to operate machinery while taking this medication, assess urine, assess skin, assess CBC, check AST and ALT
Nicoderm (nicotine transdermal) 1 patch daily @1300	Smoking deterrent	Agonist at nicotine receptors in peripheral, CNS.	Deter cigarette smoking	Dizziness, vertigo, insomnia, headache, confusion, seizures, depression, numbness, tinnitus, dysrhythmias, edema, HTN, N&V, diarrhea, abdominal pain, constipation, breathing difficulty	Change position slowly, assess sleep patterns, assess cognition, auscultate heart sounds, assess for edema, assess abdomen and bowel sounds, check BM, auscultate lungs, instruct patient not smoke while using patch for 24 hours even if patch removed, check BP
Protonix (pantoprazole) 40mg PO daily 1800	proton pump inhibitors	Binds to an enzyme in the presence of gastric acid, preventing hydrogen ions going into the stomach	Decrease symptoms of heartburn and stomach upset	Headache, insomnia, diarrhea, abdominal pain, rash, hyperglycemia	Assess bowel sounds and abdomen, check BM, assess sleep pattern and skin, check blood glucose
Prednisone (methylpredisolone) 30mg = 3 tabs PO daily with breakfast @0800 until 2-23, then 20mg daily	Corticosteroid	Decreases inflammation	Inflammation in the respiratory system	Depression, flushing, sweating, headache, mood changes, HTN, thrombophlebitis, blurred vision, nausea, pancreatitis, thrombocytopenia, immunocompromisation, hypokalemia, hyperglycemia	Check blood glucose, check platelets, check WBC count, assess stool for heme or tarry blackness, do vital signs, check potassium, assess for edema, I&O ratio

Lab	Range	Admit Result	Current Result	Clinical Day	NURSING IMPLICATIONS
WBC's	4.5-11.0 cells/mcL	5.0	4.6	3.3
RBC’s	4.6-6.0 cells/mcL	4.4	4.5	4.31	Assess for fatigue, palpitations, chest pain, SOB on exertion, and tachypnea. Check MM’s and skin color. Assess diet and look for signs of bleeding.
Hgb	12.6-17.4 gm/dL	13.5	13.2	13.3
Hct	43-49% (percentage of red blood cells)	39.1	38.7	38.3	Assess for fatigue, palpitations, chest pain, SOB on exertion, and tachypnea. Check MM’s and skin color. Assess diet and look for signs of bleeding.
Platelets	150-450 mm3	269	258	244
Glucose	65-99 mg/dL	144	215		Assess diet. Assess for increased thirst, urination, fatigue, blurred vision, and slow healing infections. Assess medications and IV fluids: corticosteroids, tricyclic antidepressants, diuretics, Protonix, epinephrine, estrogens (birth control pills and hormone replacement), lithium, phenytoin (Dilantin), salicylates, can cause high blood glucose.
Potassium	3.5-5.0 mEq/L	4.1	4.0	n/a
Sodium	135-145 mEq/L	141	138	n/a
Calcium	8.2-10.2 mg/dL	9.2	n/a	n/a
Chloride	97-107 mEq/L	102	102	n/a	Assess for dehydration (dry MMs, dry eyes, N&V or diarrhea), diuretics, corticosteroids, and laxatives may cause hypochloremia. Watch for muscle twitching, irritability, increased urination, poor appetite, sleepiness, or confusion.
BUN	8-21 mg/dL	9	20	n/a
Creatnine	0.6-1.2 mg/dL	0.8	0.8	n/a
CK	26-140 U/L	29	n/a	n/a
Phosphorus	2.5-4.5 mg/dl	2.7	8.3	n/a	Assess renal function, check blood gases, check for PE, assess respirations, assess urination
Magnesium	1.6-2.1 mg/dl	2.1	1.9	n/a
Co2	22-26 mmol/L	32	28	n/a	Check pulse ox, assess cap refill, assess for cyanosis on mouth, face, and extremities, sit patient in high Fowler’s position, administer oxygen if applicable, minimize exertion, encourage deep breathing
BNPP	< 100 pg/ml	558	n/a	n/a	Assist in differentiation of heart failure vs. pulmonary disease, assist patient to high fowlers position when applicable

XI.       

PATIENT FOCUS ASSESSMENT	NORMAL	ABNORMAL
General Survey	48 yr old female, hair is evenly dispersed throughout body according to sex, hair is lustrous, appears to be well nourished, no signs of dehydration or cachexia, affect is appropriate, speech is clear. Vital signs: BP 152/88, TEMP 97.3, sao2 96 on 4 liters of o2, HR 80, pain level is a 7 on a scale of 1-10 in the left flank.	Lacking in proper hygiene a.e.b. dried crust behind and inside external ear, between breasts, declined bathing assistance, states she “wants to do it at home.”
Head	Head is proportionately sized, face is symmetrical, smile is even, hair is evenly disbursed. Conjunctivae are pink and moist, oral mucosa is pink and moist, gums are pink, tongue is midline, throat is visibly clear and pink.
Eyes	Eyes are even and symmetrical, pupils are equal,  round, reactive and accommodating to light, no crust or exudates, lashes are intact and full, eyebrows are intact and full
Ears	Ears are even and symmetrical, no drainage or c/o pain. Responds to whisper.	External and behind the ear crust is present, indicative of subpar hygiene.
Nose and Sinuses	Nose is midline, septum is intact, no drainage or crust, sinuses nontender on palpation
Neck and Pharynx	Negative for JVD, trachea is midline, full ROM of neck. Voice is non strained and clear. No carotid bruits.
Thorax and Lungs	Chest rises and falls symmetrically. No scars, marks, or striae, no visible pulsations.	Wheezes and Rhonchi auscultated in BL lower lobes and R middle lobe, non-productive cough, labored, shallow breathing without use of accessory muscles. Pain around the sixth intercostal space that radiates to the left lower back that is r/t COPD and bronchitis, worsens on deep inspiration.
Cardiovascular	S1 and S2 auscultated no gallops, rubs, or thrills. Apical pulse palpated at 5th intercostal space. No visible pulsations on precordium. Normal sinus rhythm on the monitor with no ectopy.
Gastro-Intestinal and Abdomen	Abdomen is round, soft, non-tender, no scars, marks, or striae, no visible pulsations or hernias, umbilicus is midline and inverted. Last BM was 2-18-2009 and was typical for the patient. Positive bowel sounds in all 4 quadrants. No N&V. No pain with palpation.
Urinary	Urinates every 3 to 5 hours, pale yellow, no c/o burning or stinging, no frequency or urgency.
Neurological/Cranial Nerves/Sensory	A&O X3, speech is clear and appropriate, sensation intact without numbness, Glasgow coma scale = 15. Cranial nerves intact and functioning. Sensory perception is functional.
Motor/Musculoskeletal	Functional ROM on all limbs, +5 strength bilaterally, dorsiflexion and plantar flexion present and appropriate for patient.
Skin	Skin warm, dry, intact. No acute surgical incisions, areas of redness or breakdown.	Dry crusty areas between breasts, in external ears, and behind ears. There are two blisters on the left index and middle finger. Skin color sallow.
Peripheral Vascular	Capillary refill less than 3 seconds on extremities. Bilateral pulses on extremities are regular, rhythmic, and +2 strength.
Dressings	Not applicable
Drainage Tubes	Not applicable
IV Sites	Right AC, dated 2/17/2009, 0.45 ns @ 85ml/hr. IV line is patent and secured to arm with no surrounding redness.

  

XII.

a)    Psychosocial State:  Safety = the patient is on medications that may cause orthostatic hypotension.

b)    Subjective Concerns & Statements: “I know that this isn’t going to go away. I want to quit smoking but I just can’t. I don’t know what to do. I give up.”

c)    Psychosocial Adjustment to Illness:  She states that she smokes when she’s under stress, which in turn, stresses her out additionally.

d)    Cultural/Spiritual Needs and Concerns: Doesn’t go to church. She has no concerns about going.

e)    Patient Education Needs: Smoking cessation. I suggested it to her nurse, we’ll see if a cardiac rehab consult gets implemented. She does agree not to go outside and smoke while she is a patient, and uses Nicoderm patches.

ASSESSMENT DATA	NURSING DIAGNOSIS	PLANNING	NURSING IMPLEMENTATION	EVALUATION §  Goals §  Evaluations
S: “I couldn’t catch my breath and my chest hurt really bad.” O: X-ray showing bilateral infiltrates. O: Co2 level was elevated @ 32 upon admission. O: Expiratory and inspiratory high and low pitched wheezes and rhonchi auscultated in BL LL and RML. O: Pulse ox on admission was 90% on room air.	Ineffective airway clearance r/t bronchoconstriction, increased mucus, ineffective cough, and infection secondary to bronchitis and COPD a.e.b. client statement of SOB, radiographic testing, and nursing assessment. Scientific Rationale: - Chronic obstructive pulmonary disease (COPD) is the overall term for a group of chronic lung conditions that obstruct the airways in your lungs. COPD usually refers to obstruction caused by chronic bronchitis and emphysema, but it can also refer to damage caused by asthmatic bronchitis. In all forms of COPD, there's a blockage within the tubes and air sacs that make up your lungs, which hinders your ability to exhale. (http://www.mayoclinic.com/health/copd/DS00916, retrieved 2-18-2009) - Chronic bronchitis is an inflammation of the main air passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs and shortness of breath. In chronic bronchitis, there is excessive bronchial mucus with a productive cough for three months or more over two consecutive years without any other disease that could account for these symptoms. (http://www.copd-international.com/bronchitis.htm, retrieved 2-18-2009)	STG: The client will demonstrate proper use of the incentive spirometer by doing hourly repetitions correctly by the end of the shift. LTG: The client will maintain sao2 level above 91% while hospitalized. 1. Monitor skin color and temperature and level of consciousness q4 during vital signs. * Cyanosis, cool clammy skin, and changes in LOC (agitation, lethargy, or confusion) indicate worsening hypoxia. (LeMone, 2008 p.1329) 2. Assess pulse oximetry readings q4 during vital signs; notify the nurse of abnormal values or changes in status. * This value provides information about gas exchange and the adequacy of alveolar ventilation. A fall in oxygen saturation levels is an early indicator of impaired gas exchange. (LeMone, 2008 p.1329 3. Place in Fowler’s or high-Fowler’s position to facilitate breathing and lung expansion. * These positions reduce the work of breathing and increase lung expansion, especially basilar areas. (LeMone, 2008 p.1329) 4. Increase fluid intake. * Increasing fluids helps keep secretions thin. (LeMone, 2008 p.1329) 5. Administer oxygen as ordered. * Supplemental oxygen reduces hypoxemia. (LeMone, 2008 p.1329)	1. Monitored skin color and LOC q4 during each set of vital signs. 2. Assessed pulse ox during q4 vitals. 3. Asked patient to sit up in Fowler’s position. 4. Filled client’s water pitcher with fresh water every twice during shift. 5. Patient on 4L per NC as ordered by MD.	STG: Goal not met. The client demonstrated proper use of the incentive spirometer, but did not use on an hourly basis, even with encouragement. She said that it made her lightheaded. Reported to the nurse. LTG: Unable to assess. 1. Skin color sallow, temperature 97.6 and 97.4, no change in LOC. 2. Pulse ox readings were 96% and 97% on 4L per NC. 3. Patient sat up in Fowler’s position for an hour. 4. Patient’s fluid intake during shift was 1595ml. (Urinated 3 times during shift) 5. Patient kept NC on except for bathroom trips. (Pulse ox when returned 4 minute bathroom trip was 91%)
ASSESSMENT DATA	NURSING DIAGNOSIS	PLANNING	NURSING IMPLEMENTATION	EVALUATION §  Goals §  Evaluations
S: “It gets harder to breathe when I move around too fast.” S:”I’m just so tired lately.” S: “I’m too tired to eat and I don’t like the food.” O: CXR showed bilateral infiltrates indicative of COPD and bronchitis. O: Co2 level elevated on admission @32. O: Pulse ox on admission was 90% on room air.	Risk for imbalanced nutrition: less than body requirements r/t fatigue and dyspnea caused from physical exertion of eating. Scientific Rationale: The client with COPD fatigues easily; adequate rest is important to conserve energy and reduce fatigue. With advanced COPD, minimal activity, including eating, can cause fatigue and dyspnea. The client may be unable to consume a full meal without resting. Increased work of breathing also increases metabolic demands. (LeMone, 2008 p. 1339)	STG: The client will state her usual nutritional intake after vital signs.   LTG: A dietary consult will be implemented by nursing to assess and educate the clients eating habits during hospitalization. 1. Assess nutritional status, including diet history and any weight fluctuations and appetite. * It is important to differentiate nutritional status from body type rather than assume a nutritional impairment. (LeMone, 2008 p. 1339) 2. Suggest a dietary consult to plan meals and nutritional supplements as well as easy menu ideas for home. * More concentrated sources of high energy foods may be requires to maintain caloric intake without excess fatigue. A diet high in proteins and fat without excess carbs is recommended to minimize carbon dioxide production during metabolism. (LeMone, 2009 p. 1339) 3. Provide frequent, small snacks in between meals. * Frequent small meals help maintain intake and reduce fatigue associated with eating.(LeMone, 2008 p. 1339) 4. Place in seated or high-Fowler’s position for meals. * An upright seated position promotes lung expansion and reduces dyspnea.(LeMone, 2008 p. 1339) 5. Encourage choosing her own food by placing order with the kitchen instead of getting whatever the kitchen sends. * Providing preferred foods promotes eating more. (LeMone, 2008 p. 1339)	1. Asked about usual nutritional intake and if she has had any weight fluctuations recently. 2. Suggested a dietary consult to the nurse after showing her the client’s uneaten breakfast tray. 3. Followed the professor’s lead and gave her a couple of packets of graham crackers with jelly to snack on throughout the day. 4. Suggested going to the chair for meals, but she wanted to stay in bed. I sat her up in Fowler’s position. 5. Gave her a menu and the number to the kitchen so that she could order something that she liked.	STG: The client stated that while in the hospital, she eats about ¼ of her tray, but eats 3 to 4 patient ice creams a day. LTG: Suggested a dietary consult, and the nurse acknowledged that the client does not eat enough. Did not indicate whether or not she would implement the consult. 1. The client denied any weight loss or gain in the past six months, but did say that her appetite has decreased. She doesn’t eat “very much.” 2. The nurse agreed that the client didn’t eat enough, but did not indicate that she would order a dietary consult. 3. The client was appreciative and did snack on the crackers every hour. 4. Sat in Fowler’s position to eat but immediately wanted to take a nap after. 5. She looked over the menu and declined the opportunity to order for herself. I offered to order for her and she said that she hates the foods all the same. I brought her an ice cream.
ASSESSMENT DATA	NURSING DIAGNOSIS	PLANNING	NURSING IMPLEMENTATION	EVALUATION §  Goals §  Implementations
S: “I know I have to quit soon.” S: “I’m ashamed that I didn’t quit before.” O: Facial expression sad, looking at the wall, holding back tears.	Decisional Conflict with smoking r/t medical and nursing advice to quit smoking to improve health status. Scientific Rationale: - Smoking is more than a habit, it’s an addiction. The client who must quit is facing a significant loss, not only of nicotine, but of a lifestyle. Although the client may fully comprehend the consequence of continuing to smoke, the decisions to give into that part of his or her life is not easy. (LeMone, 2008 p. 1340)	STG: The client will at least verbally acknowledge the effects of continuing to smoke against medical advice during the shift. LTG: The client will not smoke during hospitalization. 1. Assess knowledge and understanding of the choices involved and possible consequences of each. * The decision to quit smoking ultimately belongs to the client. He or she needs a full understanding of the consequences of quitting or continuing to smoke. (LeMone, 2008 p. 1340) 2. Acknowledge concerns, values, and beliefs; listen nonjudgmentally. * The nurse needs to avoid imposing his or her values and beliefs about smoking on the client. (LeMone, 2008 p. 1340) 3. Spend time with the client, encourage expression of feelings. * This demonstrates acceptance of the client and his or her right to make the decision. (LeMone, 2009 p.1340) 4. Offer to help plan a course of action for quitting smoking collaboratively with the patient. * When the client develops the plan, he or she has more ownership in it and interest in making it work. (LeMone, 2008 p. 1340) 5. Demonstrate the right for decisions and the right to choose. * Respect supports self-esteem and the ability to cope. (LeMone, 2008 p. 1340)	1. Asked the client is she understood her options of quitting or not. 2. Let the patient speak about her reasoning for smoking with a nonjudgmental attitude. 3. I asked the client if she thought she was strong enough now to quit. 4. Offered to have the nurse request a cardiac rehab consult which educated clients on smoking cessation and gives them a lot of information about support groups, etc. 5. Did not show any disappointment or disagreement.	STG: Goal met. The client stated that she is aware of the risks of continuing to smoke and she wants to quit but can’t. LTG: Unable to assess, however, patient was compliant with orders not the leave the unit d/t being on telemetry and did allow nicotine patches to be administered. 1. She stated that she understood that her condition will never get better, but she will be able to keep it under control if she quits now. 2. She gave excuses as to why she hasn’t quit yet: marital problems, parent’s illness, money stress. I explained that I quit after 10years of smoking, so I understood how difficult it can be. 3. She said that she thinks so once she gets her husband out of the house. 4. She declined the offer. 5. I explained that I knew she will quit when she is ready. We all need our own time to make the choice.