Nursing Diagnosis

Throughout my clinical rotation, the only concern for this patient was pain management and discomfort from the chest tube site. The patient was given Ketorolac for a pain of 4/10 using the numeric pain sale. The patient was also at risk for pneumonia and pressure ulcers from immobility and not coughing/deep breathing. Nursing interventions were getting the patient up to the chair and using the incentive spirometer ten-times per hour. Another concern was SOB and fatigue with activities.

Our client, Ertha Williams is a 99 year old female who lives alone in a low-income apartment complex on the second floor in Monroe, Michigan. Ertha suffers from chronic kidney disease and has a history of hypertension and type one diabetes. Due to her chronic kidney disease Ertha has regular scheduled dialysis appointments three times a week, but since the death of her son and husband and her inability to drive it is difficult for Ertha to get to her dialysis appointments. She also has difficulties preparing the multiple medication she is required to take to manage her hypertension and diabetes. After her last dialysis appointment the nurse reported that Ertha appeared frail and emaciated. Ertha herself also stated that she worries about financial issues frequently and has good and bad days occasionally. Based on these findings Ertha is in need of some assistance to help alleviate some of the problems and stresses she is undergoing. Several nursing diagnoses can be established based on Ertha’s current situation and through these diagnoses it will be easier to establish what kind of services Ertha will need from the surrounding community of Monroe and what types of barriers she might encounter in attempting to access these services.

My two nursing diagnoses would be social isolation related to cultural difference as evidence by patient speaking Spanish as a first language. The rational for that would be that the no one can speak Spanish fluently and is a different culture from me. We would need to get an interpreter to help interpret for us between the patient and the healthcare team. They would need to book a service for someone to either come into the office or have them interpret over the internet like skype. I would evaluate it by seeing if the communication between the patient and the health care team is able to translate all the word and that the patient understands everything that is going on. My second one would be impaired verbal communication related to sensory

This essay provides a written account of the holistic assessment used when admitting a patient onto a respiratory ward. A brief outline is also included of the processes involved together with the resources used for collating information. Using the Roper, Logan and Tierney activities of daily living (ADL’s), eating and drinking, has been identified as one goal of nursing care. A short reflection has also been included based on experiences gained on a first clinical placement on the ward. For the benefit of this essay the selected patient will be referred to as Mrs P in order to maintain confidentiality.

The North American Nursing Diagnosis Association uses Gordon’s Framework as a foundation for its nursing diagnosis (Edelman &Mandle 2014). Gordon’s framework consists of functional health patterns as defined by Endleman and Mandle (2014) is,” viewing the individual as a whole being using interrelated behavioral areas” (p. 150). There are eleven patterns used as a tool to collect information during assessments in order to create a plan for validation and communication among the nursing profession. It focuses on five areas; pattern, individual –environment, age –development, functional and lastly cultural. With the various detailed questions related to the health perception, is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient. Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a comprehensive nursing data base. These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

From investigation in health practices, ventilator associated pneumonia caught my attention. “Ventilator Associated Pneumonia (VAP) is a leading cause of morbidity and mortality in intensive care units. Most episodes of VAP are thought to develop from the aspiration of oropharyngeal secretions containing potentially pathogenic organisms. Aspiration of gastric secretions may also contribute, though likely a lesser degree. Tracheal intubation interrupts the body’s anatomic and physiologic defenses against aspiration, making mechanical ventilation a major risk for Ventilator Associated Pneumonia. Semi-recumbent positioning of mechanically ventilated patients may help reduce the incidence of gastroesophageal reflux and lead to a decreased incidence of VAP. The one randomized trial to date of semi- recumbent positioning shows it to be an effective method of reducing VAP. Immobility in critically ill patients leads to atelectasis and decreased clearance of bronchopulmonary secretions. The accumulation of contaminated oropharyngeal secretions above the endotracheal tube cuff may contribute to the risk of aspiration. Removing these

Deficient fluid volume happens when there is a significant loss of fluid and electrolytes as with excessive sweating. Dehydration can occur from an insufficient fluid intake, excessive fluid loss, and fluid shifts. The first sign of dehydration is thirst. If the patient would have drunk water when he first became thirsty, him collapsing may not have occurred, and no further treatment may not have been needed. If fluids continue to be lost, the heart pumps faster but is rapid and weak and causes orthostatic hypotension, explaining his pulse being 136 and blood pressure being 88/52. Orthostatic hypotension may have caused him to collapse due to the

Nurses use the enhanced nutritional care by screening the patient using the “Malnutrition Universal Screening Tool” (MUST) to discover if patients are malnourished, deciding on what to do prevent the patient from malnutrition by monitoring and observing the patient when they eat, improving their preference of food to make sure patients have a balanced diet, and evaluating if patients are eating what they receive from nurses and if they are properly nourished. The RCN’s “Nutrition Now” campaign has made preventing malnutrition a goal by creating principles, such as being responsible for making changes to nutrition and hydration care plans, since “nutrition is essential for life, as vital as medication and other types of treatment” (Royal College of Nursing, 2016). Using the enhanced nutritional care principles, the Canadian Malnutrition Task Force created the Integrated Nutritional Pathway for Acute Care (INPAC) algorithm for discovering, treating and monitoring patients who are malnourished in acute

Patient /caregiver knows the suitable and correct choice of the dietary intake when she is discharged to home.

The first assessment I performed for my patient, C.P., was during a day shift on February 23, 2016. Upon receiving her into my care at approximately 0730hrs, I noticed that she was extremely difficult to rouse awake as she was drowsy and could not seem to keep her eyes open. On top of this, she was exhibiting unusually slow respirations while laying supine on her bed, with many blankets around her. For the purpose of this paper, I will be focusing on my respiratory assessment. During this event, performing a thorough respiratory assessment was challenging because C.P. was unable to fully participate due to her current cognitive state.

Oronasal mask was used with all subjects to start NIV. Manually and/or Mechanically Assisted Cough - manually assisted cough was employed to provide optimal insufflations. Portable ventilator was used to deliver deep insufflations. Both assisted coughs were administered for the first 3 days of the home care practical by a respiratory care therapist, who visited the patients every morning. They trained them for 3 days how to use NIV. The pulmonology also visited the subjects for the first three days. The nurses visited the patients mornings and afternoons until recover them not to getting worst.

The nurses’ role in establishing nutritional care for Tim would be to have a continuous assessment of his needed calorie intake per day and coordinating with the hospitals dietian to help coordinate a diet plan for the patient. By having a dietitian meet with the patient allows the patient to express the foods patient’s likes and dislike. In the role of the nurse he/she would be responsible for routine lab work, daily weights, noting the patients I &O’s and frequently reassessing Tim’s nutritional needs.

Standards of care are the baseline for proving quality of care and govern the practice of nursing. Adherence to these standards helps ensure safety and achieving better client outcomes. The main purpose of standards of nursing practice to promote, guide and direct nursing practice. Provides framework for developing competencies; it outlines what the profession expects of its members to deliver quality of care and patient safety.

The second nursing concern is impaired gas exchange for patient with COPD, this may be related to; alter oxygen supply, alveoli destruction and alveolar capillary membrane changes. The nursing intervention of this would be, to elevate the head of the bed up to help the patient breathe easier, to assess the skin and the membrane for color changes and to encourage the patient to cough to help clear secretion, as well as, to monitor the level of consciousness and mental status. The expected outcomes would be that the patient shows improvement of ventilation and oxygenation of their tissues and by assessing the ABGs and to be free of respiratory distress (Vera, 2013).

COMMUNITY COLLEGE OF PHILADELPHIA DEPARTMENT OF NURSING NURSING CARE PLAN Student: Novlet Stapleton Client Initials: E. S. Age: 90 Nursing Diagnosis: Impaired gas exchange related to a decrease in effective lung surface associated with bacterial lung infection