The purpose of this project is to become familiarized with factual case studies, become content with collecting data, formalizing nursing diagnosis, and interventions. This project will help us learn how to essentially connect our health assessment and pathophysiology education. After completing this project we will be able to devise nursing diagnosis and interventions confidently and become further knowledgeable about the necessary subject matters. Nursing Physical Assessment The patient presented to our group is a 68 year old African American woman who has a history of hypertension, apparent asthma, hyperlipidemia, and osteoarthritis. She has had a hysterectomy and a family history of noncontributory. Home medications consist of Spironalactone 50mg p.o. daily. Patient lives at home with her family; she hasn’t had any form of tobacco in over 30 years and does not consume any form of alcohol. Client was in her typical state of health up until last Tuesday; which is when she began to have lower quadrant abdominal pain. Subjective data collected was “there was more pain on …show more content…
Hypovolemia is also known as deficient fluid volume in the blood. This disorder is fluid and electrolyte imbalance which is evidenced by our client’s blood results. With hypovolemia, your cells are fluid and electrolyte deprived and can either cause the lysing or crenation of your cells. One of the causes of hypovolemia is frequent loss of fluid, which coincides with our client’s diagnosis of urge incontinence. One of the electrolyte imbalances that our patient had was hypokalemia. Hypokalemia is a potassium level that is lower than the normal range or 3.5. Mild symptoms of hypokalemia include, abnormal heart rhythms (dysrhythmias), especially in people with heart disease, constipation feeling of skipped heart beats or palpitations, fatigue muscle damage, muscle weakness or spasms, tingling or numbness (Saunders,
The SMART goal for the patient’s diagnosis of diarrhea is that the patient will defecate formed, soft stool every 1 to 3 days and will express relief of cramping with little or no diarrhea. The intervention to meet this smart goal is the administration of fidaxomicin, a narrow spectrum antibiotic, to treat the infection of Clostridium difficile (Sears, 2013). Another nursing intervention for the treatment of diarrhea is assessing the patient for sodium and potassium loss, as well as explaining the prevention methods to avoid the spread of excessive diarrhea (Mitchell, 2014). The nurse must also provide proper skin integrity care to the peritoneal are and make the environment safe and easy for access to the bathroom. The SMART goal for the patient’s diagnosis of acute pain is that the patient will state relief of pain in abdominal area after treatment with opioids in a 24hr period. The nursing intervention for acute pain is the administration of opioids as well as positioning to keep patient in as much comfort as possible and take pressure off of the abdominal area. The nurse must also assess the patient’s vital signs and pain level
She had a two week history of feeling generally unwell, complaining of tiredness and lethargy. She had no other significant symptoms. Her past history includes well controlled asthma and anxiety. She was a smoker of 20 cigarettes per day. She was taking amitriptyline, Symbicort (budesonide and formoterol inhaler). She had no significant family history of medical illness and had no clinical findings on examination. Blood tests showed corrected calcium of 4.22mmol/L (NR 2.20 -2.60) with suppressed paired PTH of 1.45pmol/L (NR1.60- 6.9). Her renal function was initially impaired, but normalized with rehydration. Her liver function tests, full blood count, vitamin D, myeloma screen and serum ACE levels were all within normal limits. Ultra sound scan (USS) of kidneys, USS of parathyroid and computerized tomography (CT) of thorax, abdomen and pelvis were all reported as normal with no cause found for her
This can be investigated by a range of procedures. These include a CT scan of the kidneys and bladder in conjunction with an abdominal X-ray. Results obtained from the diagnosis and tests enable judgments’ relating to the stage to which the problem has developed and will inform decisions on the appropriate treatment
Since this patient is having acute abdominal pain, a focused acute abdominal assessment needs to be conducted to identify the cause of her pain. For this patient, a quick focused history related to abdominal issues is to be conducted, then a focused abdominal physical exam (Jensen, 2011). Since abdominal pain can be tricky to
A diagnosis is the expert and clinical judgment of the patient 's present or potential medical issue. During the 1970s and 1980s, a controversy about nurses using the term “diagnosis” began. Up until then, only physicians held the ability to diagnose a patient. But the nursing diagnosis is completely different than a medical diagnosis. In other words, a nursing diagnosis is a judgment based on a comprehensive nursing assessment (NANDA, 2013). Nursing diagnoses must be promoted by data or signs and symptoms.
The patient is a 56-year-old gentleman who presented to the ED with a complaint of constipation for 5 days prior to presentation patient reports child the being bags of sunflower seeds 6 days prior to presentation and since that time he has not had a bowel movement. He reports some associated left lower quadrant pain 2/10, sharp and constant. He also reports associated increased urinary frequency and straining to urinate. He has no significant past medical history. He has tried some stool softeners etc. at home with no results. Clinical review of his records indicates he does have a mild elevation in his white count with a left shift. His SMA-18 reveals some hypokalemia. Urinalysis reveals a small amount of blood. A CT the abdomen
constant pain in upper abdomen, and people can be disabling due to severe pain, weight loss
ANA describes “The Scope of Nursing Practice (as) the “who,” “what,” “where,” “when,” “why,” and “how’ (8).’ In other words, it is the responsibility of the nurse to know who their patient is, what the patient’s diagnosis and treatment are, where it is they will be delivering treatment, the rationale behind their actions, and how they will deliver the care. By following the scope of practice, nurses reduce avoidable errors and are aware of the liability their actions entail. The ANA also puts forth a nursing process to guide nurses in treatment. The constantly evolving process is currently assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation (ANA 9). Though this method has dramatically improved nursing care, it may be necessary to repeat steps to adapt to a patient’s changing needs and pathologies. By following guidelines set by the ANA, nurses are able to better connect with their patients and instill the image of professionalism to the public while also optimizing safety
Price, N. and Currie, I. (2010) ‘Urinary Incontinence in women: diagnosis and management’, Practitioner, 254(1727).
This was his second episode since 10 days ago where he develop the same pain at his right flank. He suddenly experienced severe pain 8 hours before admission when the pain shifts to his right lower quadrant of his abdomen. The onset is at 6.30 am before worsening at 10 p.m to 2 p.m. He described the pain as continuous sharp pain and gradually increased in severity. There is no radiation of the pain. The pain was exaggerated on movement and touch. There were no relieving factor and he scale the severity as 7/10. He experienced fever for 1 day prior to admission. It was a mild grade continuous fever. He does not experienced chills and rigor. The patient does not experience any nausea or vomiting, no dysphagia, no pain during micturition and no alteration in bowel habit. He experienced loss of appetite but not notice any weight loss.
For the outcome, Clinical Competence I have learned the importance of the nursing process in my current class, Skills and Concepts. This information is relatively new to me, so I know I have plenty of room to grow in this area. I have learned how to utilize the resources that I am provided. One resource in particular is my pocket guide. This has been a useful tool in helping learn and write a nursing diagnosis based upon a given situation. As I progress through the rest of this class; I hope by the end to be more competent in ways of providing the best possible care while utilizing the nursing process.
The nursing process is one of the most fundamental yet crucial aspects of the nursing profession. It guides patient care in a manner that creates an effective, safe, and health promoting process. The purpose and focus of this assessment paper is to detail the core aspects of the nursing process and creating nursing diagnoses for patients in a formal paper. The nursing process allows nurses to identify a patient’s health status, their current health problems, and also identify any potential health risks the patient may have. The nursing process is a broad assessment tool that can be applied to every patient but results in an individualized care plan tailored to the most important needs of the patient. The nurse can then implement this outcome oriented care plan and then evaluate and modify it to fit the patient’s progress (Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P., 2011). The nursing process prioritizes care, creates safety checks so that essential assessments are not missing, and creates an organized routine, allowing nurses to be both efficient and responsible.
I can continue to improve my performance by practicing my assessments. I also need to practice my occupied bed making. I should review my patient information several time before entering the hospital. I need to take advantage of fitting in assessment time with my instructor. I should look up nursing diagnosis, interventions, and outcomes before clinical. Moreover, I need to figure out the abnormal lab values that are associated with my patient’s diagnosis and grasp and understanding of what is going on with my patient.
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
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.