Disturbed Sensory Perception and Poor Circulation
A nursing diagnosis is a way the nurse summarizes a patient’s treatment by identifying abnormal neurological, psychological, emotion and physiological symptoms and future exams or questions that lead to information that can lead to identifying the cause of condition that applies treatment to help get the patient back to living a quality life (Nurse Theory, 2018). The purpose of this paper is to consider the evaluated assessment of Ms. Jones and identify two nursing diagnosis.
Ms. Jones a 28-year-old female who presented to the emergency department for evaluation of right foot pain, fever, and nausea and admitted to the hospital for Iv antibiotics. The scrape is red and swollen with exudate and
…show more content…
Jones is a diabetic and does not take prescription medication due to stomach issues when taking the medication. Due to an open wound on lower extremity and diabetes, a neurological exam assessment is initiated. Patient’s vitals were, 122/84, pulse 69, respirations 16, 98% saturation, 36.7 C/ 98.1 F, and she rates her pain at a 6 on a scale of 0-10. After neurological history, review of systems, psychiatric history and through assessment of the patient’s neurological system it is determined that the evaluation reports disturbed sensory perception related to her infected foot wound, poor circulation due to diabetes, impaired healing, and an unsteady gait due to foot injury and not wanting to place foot on the floor due to pain. Based on the information gathered during assessments, two nursing diagnosis determined for Ms. Jones are disturbed sensory perception and poor …show more content…
The recommendation is to emphasize finding a customized eating plan based on the personal needs, cultural preferences, and the ability to access to healthful selections. The primary goal of the modified diet therapy is to improve health by providing calories for normal development and growth while achieving and maintaining ideal glycemia and normalizing dyslipidemia. So, diets are often altered with respect to the amount of carbohydrate, the type of fat, and the type of protein to meet these needs of everyone (Bajaj, 2018). Nutrition is a huge part of the management of diabetes and providing proper wound healing
The nurse needs to describe what focused health assessments they think would best suit the patient. The nurse needs to work out a way in which we can help decrease Alice’s heart rate and blood pressure. To do this the nurse would perform a neurological assessment and a head to toe assessment. These two assessments will give the nurse more information about Alice’s nervous system, if she is in any pain and what further assessments and treatment need to be completed. A neurological assessment is a technique of gaining specific data in relation to the role of a patient’s nervous system (Ruben Restrepo).
Nursing diagnosis is a clinical assessment of health problems experienced by a family or an individual and their response to this health problem. It helps in determination of interventions that are to be put in place so as to realize the desired outcome. This diagnosis enables the nurse to come up with a care plan for the patient (National institute of health, 2002).
One of the nursing nomenclature used in my work setting that is recognized by the American Nurses Association (ANA) is the North American Nursing Diagnosis Association International (NANDA-I). According to Cavalcante, Brunori, Lopes, Silva, and Herdman (2015), the purpose of NANDA-I is to provide a common language in the nursing profession whereby nurses can consistently and accurately document health problems as they are related to clinical assessment findings. Furthermore, Cavalcante et al. implies that the concept of these nursing diagnosis informs nurses about the nature of and care activities required for a specific health problem. The concepts assist nurses through the clinical reasoning process to assess the holistic needs of the patients,
Healthcare is always evolving and the demand to improve patient outcome is tremendous and it has changed the way we provide service. This paper will first review the phenomenon of interest, and then discuss about nursing meta-paradigm, grand nursing theory, middle range nursing theory, complexity science, and ethical framework and how they are applied to my POI.
Wilson, Susan. (2009). Health Assessment for Nursing Practice (5th ed., pp. 520-521). St. Louis, MO: Elsevier Mosby.
This paper will outline each nursing strands and then explain how each of these strands fit into a personal nursing experience in healthcare setting. As a nurse, it is very important to provide proper care to the patient as nursing is a very difficult and fast pace job. Self- evaluation provides personal responsibility and development of the professional plan in order to meet each goal or strands in nursing practice.
Left hallux was deteriorated further from last week’s pictures, which required an aspiration from the lesion to investigate further whether this lesion is infected again. Left fourth and fifth inter-digital ulcerations were not improved, and right dorsum of second digit’s ulcerated wound was epithelised. Saline flushed and mildly debride the lesions with blacks file and mosquito forceps. Wound dressed with bactroban, baitain and mefix on left hallux, and baitain with mefix on other
As nurses and future NPs, we have to look at a patient in a holistic manner. If the patient shows signs and symptoms pertinent to only one body system, you would not just look at that particular system. Rather you would conduct a head-to-toe assessment to rule out or rule in other diseases and do a more thorough examination on the system that the patient has specific complaints about.
Nursing diagnosis reference manual (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing:
St. Louis, MO: Elsevier Ackley, B.J., Ladwig, G.B., & Flynn Makic, M. (2017). Nursing diagnosis handbook (11th ed.). St. Louis, MO: Elsevier University.
Actual or potential health problem that can be prevented or resolved by independent nursing intervention are termed nursing diagnosis. (Taylor, 2015, p. 254) Diagnosis is the second step of the nursing process. It is very critical part for nurses to analysis and interpret the patients’ data according to their strength and health problem. After assessment of patient’s sign and symptoms, nurse has to prioritize list of nursing diagnosis, which determine actual and potential risk factors. Medical diagnosis deal with disease or patient pathology, which can be detected by physician and directs primary treatment of disease, whereas nursing diagnosis focuses on human response which gives holistic care to the patient’s actual and potential
Our approach in managing wounds was far from being optimal in our own setting. After having read the article of Sibbald et al (1) and assisting to presentations during the first residential week-end, our approach at St. Mary 's Hospital Center 's Family Medicine Clinic must change. We were not classifying wounds as healable, maintenance or non-healable. We were always considering the wounds in our practice as healable despite considering the system 's restraints or the patients ' preferences. In the following lines, I will define and summarize the methods one should use in order to initial management of wounds and how to integrate it better to our site. The first goal we need to set is to determine its ability to heal. In order to ascertain if a wound is healable, maintenance or a non-healable wound.
Gordon, M. (2007). Manual of nursing diagnosis: including all diagnostic categories approved by the North American Nursing Diagnosis Association (11th ed.). Sudbury, Massachusetts: Jones and Bartlett.
Patients may present with symptoms and signs limited to the foot or with systemic problems.
Inadequate data collection from patients is unacceptable, which is why it is necessary to have and implement health assessment frameworks or strategies. Health or nursing assessments are continuous cycles of data collection and making inferences. There are steps to be taken to ensure adequate collection of objective and subjective data, these steps need to be taken in order otherwise an inaccurate assessment may occur. These steps are: assessment, diagnosis, planning, implementing and evaluation (Lewis, Foley, Weber, & Kelley, 2011, p. 2-5). Nursing assessments aim to collect subjective and objective data to determine a patient's overall functionality in order to make a clinical judgment, the nurse collects data relating to all areas of individual health. It is my opinion that appropriate health assessments are necessary to ensure a patient receives the correct treatment plan. All health assessment frameworks follow the same steps in organizing treatment, due to the wide scope of nursing disciplines there are varying focuses on these individual steps i.e. the emergency room could be more focused on the assessment in order to triage the patient. To help alleviate the patients or family members who may be distraught a health professional should take the time to expla...