3-Part Nursing Diagnosis

This assignment will critically discuss the nurse’s role in assessment and care planning for a patient in a case study. Confidentiality which is required by the NMC (Nursing Midwifery Council, 2008) and the Data protection Act (1998) will not be broken through out the assignment because the case study used is a scenario not a fictional character. The care plan will focus on Jean’s incontinence needs using The Roper, Logan and Tierney model (2000).

State in your own words what you would say to this patient to explain why she is unable to eat or drink (relate to diagnosis).

Ertha’s most prominent issues are her inability to get to her prescribed dialysis appointments three times a week and the difficulties she has in preparing her medications. Based on this evidence a nursing diagnosis of ineffective health

As nurses, we are the frontline advocates for our elderly patient, because the patient might be reluctant to share information about the abuse they are experiencing. When doing head to toe assessments nurses are in a position to see signs of abuse of medication, physical abuse, neglect, and sexual abuse. These type pf abuse can be seen through skin assessment; finding of bedsores (pressure sore, decubitus ulcers), bruises, broken bone, poor hygiene, dehydration over or under medication, and an overgrown nail are really good indicator of abuse. There is also mental cues for abuse such as, depression, sudden change of behavior, fearfulness, anxiety, and confusion. Most of these findings are objective, but it can be hard to obtain subjective

Assessment is the first part of the nursing process and thus forms the basis of the care plan. The essential requirement of accurate assessment is to view the patients holistically and thus identify their real needs. The general survey of an assessment gives a broad range of impression of the individual.

Explain why a nurse’s initial assessment is so important to a patient’s nutritional status. What should be considered? Use evidence from one scholarly source other than your textbook to support your answer. Use APA format to cite your source.

State in your own words what you would say to this patient to explain why she is unable to eat or drink (relate to diagnosis).

Lily was a 65 year old lady with stage 5 CKD, she had recently begun hemodialysis treatment three times a week as an inpatient and had been responding well to treatment. During dialysis treatment on the morning of the first day, Lily’s observations showed that she was: tachycardic, hypotensive, tachypnoeaic, had an oxygen saturation level of 88% and was becoming confused and drowsy. It became apparent that Lily had become hypovolaemic. The hypovolaemic shock seen in this patient was of a particular critical nature due to the fact that her dialysis treatment had moved her rapidly through the first two stages of shock with her compensatory mechanisms failing very quickly (Tait, 2012). It was also much harder to identify the early signs of

Ineffective coping r/t past situational crises, unresolved emotional conflict between patient and wife, destructive behavior towards self, increased depressive state and unpredictable episodes of anger and aggression s/t sleep apnea AEB disturbed images of past crises, demands on family imposed by the patients current condition, increased state of depression, disturbed sleeping patterns since returning from deployment, a torn ligament in wrist from episode of anger and aggression, presence of tension headaches, increase use of alcohol during the week and unable to identify triggers leading to angry and aggressive episodes.

Likewise, we may need dietician participation to improve nutritional status. It is necessary to meet his nutritional need to recover his present health condition. Therefore, I will ring the dietician to review him and request to start his feed considering his present health status. To establish goals and take action for pain management is also vital. As an immediate action, I will administer charted PRN analgesics as per order. But, for long-term goal during his hospital stay, I will request the doctor to chart strong PCA medication. Further, I will encourage him to remind me whenever he feels thirsty because I will administer bolus of fluid through nasogastric tube to keep him

Presenting symptoms may imply more than hints to a disease which is a potential progression, the right attitudes for a nursing professional to manage symptoms are to understand the person’s experience and the meaning of related with every symptoms (Heaworth & Dluhy, 2001).

Vitals signs include a person's temperature, pulse, respiration, blood pressure, pain, and the pulse oximetry as well (Taylor, Lillis, & Lynn, 2015, p. 579). They are important to be assessed routinely on every patient because the health status of a person is reflected in these vital signs since they are the indicators of body functions, and a change in vital signs allows the nurse or any other healthcare professional to know if there is anything wrong with the patient by being able to do a diagnosis, perform lab tests, and plan for interventions for those specific indications. Nurses assess vital signs for each patient and use them to compare their findings to accepted normal values and the patient's usual pattern of values.

Moore (2004) argues that in order to treat patients adequately, nurses should possess a thorough understanding of aetiology, clinical presentations and treatment of the three leading diabetic emergencies: hyperosmolar non-ketotic syndrome, hypoglycaemia and diabetic ketoacidosis. DKA is a life-threatening medical emergency that can result in coma or even death if medical treatment is not administered (Moore, 2004). Prior to insulin discovery, DKA was customarily fatal, with ketoacidotic coma being the usual cause of death (Palmer, 2004). Ketoacidosis occurs due to a deficiency of insulin and an excess of counter-regulatory hormone. Lack of insulin results in reduced glucose uptake

Nursing Diagnosis 1: Ineffective cerebral tissue perfusion related to interruption of blow flow secondary to CVA. Evidence by patient medical diagnosis of CVA. (Carpenito 2014)

Suggest patient to keep the record of the input and output during hospitalization and discharge.