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In formulating a care plan, it is important to note that the environment plays a significant role in the movement from an exacerbation of a chronic illness to stability. According to Florence Nightingale, the important elements for the patient under nursing care are: personal hygiene, nutrition, ventilation, room temperature, sanitation, lighting, waste disposal systems, noise, beddings and water quality. However, everything in the patient’s environment, including equipment, must be taken into consideration. The environment also includes comfort, presence of the nurse, stimulation, communication of health advice as well as inspiring hope. The goal of nursing care is to make sure that the patient’s environment promotes health. This means that the environment must not be a source of stress or further disease, but should provide the patient’s physiological, psychological and social needs.

The care and assessment data towards the patient is the focus; it is obtained through careful observation and conducting a patient interview. With empathy and active listening, the nurse engages the patient in a conversation. Mr. Issler states that he is unsure if he has hypo or hyperthyroidism but indicates to the bottle of Synthroid as his thyroid medication. He has not been compliant with follow-ups and regular blood draws for T4 levels. As a result, he went from a hypo to a hyperthyroid condition. He also is dyspneic from pulmonary congestion secondary to CHF. This keeps him awake at night. Further, he states he has not had much appetite following his wife’s death. The wife cooked meals for and took care of him. His BMI is normal but states he has lost weight. He felt desperate lately that he had to call his daughter-in-law for help. He is anxious about his condition, fearing he might not get better.             

Based on assessment, the following are the patient’s primary areas of needs: nutrition, sleep, oxygenation, knowledge about medical condition and social support system. The nurse then proceeds to modify the environment to fulfill these needs. Oxygenation is the priority problem and the aim of interventions is to ease his dyspnea. His bed is positioned at high Fowler’s. The nurse also ensures a quiet and relaxing atmosphere so that the patient can get enough rest and sleep. Moreover, the nurse assists in relieving anxiety, which can increase the respiratory rate, and this is done by allowing the patient to verbalize his feelings.   

With regard to nutrition, one goal is to prevent further weight loss and maintain the patient’s BMI within the normal range. The other goal is to prevent fluid retention by reducing sodium intake. Adequate nutrition and an appropriate diet will provide the energy to fulfill activities of daily living, while preventing a worsening of his condition. The nurse then coordinates with the dietary department to give the patient low-fat, low-salt meals which incorporate his preferences. Since food seems to remind him of his wife and her loss, the presence of the nurse during meal times for company and encouragement creates a situation more conducive to eating.

Finally, the nurse empowers the patient by teaching him about his co-morbid conditions and the clinical and self management involvement. The goal is to promote effective coping with chronic illness to optimize health outcomes and prevent hospitalizations. Health education will emphasize compliance with medications, follow-up visits, diet and physical activity and promote self-care, all of which increase his quality of life. Prior to discharge, the nurse will also discuss with him and his daughter-in-law the home environment to guarantee that it will be healthy for him. The nurse also explores with him groups or organizations which he can tap for social support, such as a church. She/he facilitates a discussion of his future plans, the possible activities he can do with his grandchildren and hobbies and other leisure activities he can pursue. A focus on the future with its numerous possibilities helps the patient to regain optimism, a sense of purpose and hope.

The nursing care plan above reflects the theoretical statement that the physical and social environment can influence patient’s health. In fulfilling the role of a nurse in Florence Nightingale’s environmental theory, modifying the environment is not done mechanically but in a patient-centered and holistic way. The patient’s needs and preferences ultimately define what the interventions are and these address not only physiologic needs but also psychosocial and even spiritual needs. The environment is expanded beyond the physical to also include the social environment where the nurse is a key element. Assessment techniques advocated by Nightingale assist the nurse in creating an appropriate care plan.

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