In order to accomplish some goal or purpose in the health care arena by the Register Nurse (RN) the American Nursing Association published in 1973 The Standards of Practice that after many years going thru revision is developed in to the nursing process that have five steps that include Assessment, Diagnosis, outcome identification and planning as well as Evaluation. (Doenges, Moorhouse, & Murr, 2013) For the purpose of this week this discussion the learner will develop a individualized plan of care using the five nursing process for a confused 86 year old patient who was admitted after falling at home and has a right hip fracture that will be repaired.
Assessment: The goal of the assessment is to gather as much information from the interview and physical examination, with concentration on the patient pain level during the assessment (Doenges, Moorhouse, & Murr, 2013). Starting with the vital signs obtaining objective (what the RN gather form the assessment) and subjective (what the patient can tell us) information from patient and family members since patient is confused to placed and time. The rationale is that after the fracture anticipating pain is expected due to tissue damage that contributes to distress; since pain is subjective the best way to evaluated it is to use a scale or faces to give the RN objective information. Describing the location, characteristics is important because it will give the member of the health team a way to identify the cause of the discomfort and to keep on assessment to avoid developing a more serious the problem.
Diagnosis: is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnos...
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...t nursing process, involves determining whether the client goals have been met, partially met, or not met. If the goal has been met, the nurse must then decide whether nursing activities will cease or continue in order for status to be maintained. If the goal has been partially met or not been met, the nurse must reassess the situation (Doenges, Moorhouse, & Murr, 2013) For this particular client describes and rates pain on scale of 0 to 10,use pharmacologic measures to reduce discomfort and to asked for pain medications and uses pain relief measures early in pain cycle.
In closing when it comes to the nursing process the RN needed to used critical thinking, used all of the their senses when assessing this particular patient, with fracture gather vision, touch and hearing information vital for the comfort of the client (Doenges, Moorhouse, & Murr, 2013).
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