Physical Examination Of Nursing Diagnosis And The Nursing Process Of Care

Management of the acutely ill adult is a complex and perplexed procedure. It requires underpinning knowledge of the pathophysiology of the disease currently affecting the patient, as well as ensuring that professionals are equipped to deal with the development of a rapid deterioration. The National Institute for Clinical Excellence (2007) explain that patients are sometimes inadequately treated due to staff not acting in a sufficient time manner, and so a systematic assessment of the patient recommended by the Resuscitation Council (2006) should initially be followed (Jevon, 2009).

Blackman’s complaints, signs, and symptoms were downplayed and eventually he was transferred out of the PACU with no further plan of care, assessment of the issues, or action to alleviate his complaints. 3 days postoperative, with continued scheduled Ketorolac administration, Lewis’ pain was unfathomable. Despite repeated attempts to gain the attention of the healthcare team to Blackman’s impending crisis, his pain was once again downplayed. The nurses again failed to recognize the significance of his increasing abdominal pain and deterioration, chalking it up to gas pain, suggesting only movement and a bath as the acceptable plan of care. Lewis’ symptoms continued to progress and he deteriorated to a state of clinical shock evidenced by abnormally low temperature and increased heart rate and respiratory rate accompanied by extreme paleness, enlarged abdomen, with absent bowel sounds. Inexperience, lack of recognition, and failure to rescue eventually led to the unexpected death of Lewis Blackman (Acquaviva, et al., 2013).

As Jane was presenting with a symptom of a life threatening event it was important that treatment was immediate. Priority was initially made from assessment of the airways, breathing and circulation, level of consciousness and pain. Jane’s respirations on admission were recorded at a rate of 28 breaths per minute, she looked cyanosed. Jane’s other clinical observations recorded a heart rate of 105 beats per minute (sinus tachycardia), blood pressure (BP) of 140/85 and oxygen saturation (SPO2) on room air 87%. It is important to establish a base line so that the nurse is altered to sudden deterioration in the patient’s clinical condition. Jane’s PEWS score (Physiological Early Warning Score) was 4 and indicated a need for urgent medical attention (BTS 2006). Breathing was the most obvious issue and was the immediate priority.

The primary problem is the patient is having severe dehydration due to excessively having loose liquidly stools for the past two days caused by C. Diff.

This essay sets out to discuss the importance of comprehensive and accurate assessment on a registered nurses’ ability to make excellent clinical decisions. It will examine what factors can change a nurses’ capability to be aware of, and act on abnormal assessment findings. As well as assessment being part of the nursing process that is used in every day nursing, it is also a critical part of patient safety (Higgins, 2008). Assessment findings are used to determine what needs to be done for the patient next. Early warning scoring systems currently exist to aid in the early detection of patient deterioration (Goldhill, 2005). The rationale for the use of these systems is that early recognition of deterioration in the vital signs of a

This 49-year-old African-American female was presented to Truman Medical Center - Emergency Department, on November 24, 2014 due to nausea, vomiting, and headaches for two days. She stated that she has no appetite and left lower quadrant pain. She was previously treated at Saint Luke Hospital - Emergency Department for her diarrhea, nausea and vomiting before transferred to TMC Hospital. At SLH - ED, she was given some Benadryl, Tylenol and IVF which showed no improvement and continue to have three to four times watery diarrhea with no blood or mucus associated with nausea and vomiting. Her medical history is significant of diabetes mellitus type 2, hypertension, intracardiac loop recorder and cerebro-vascular disease. Vital signs included a high oral temperature

Despite the best efforts to stay healthy, periodic problems with one’s health are an unavoidable part of life. While many of these injuries or illnesses will pass without problem even if untreated, every person will almost inevitably face the occasional health issue that demands attention. The appropriate response to this ailment may involve going to a hospital to consult a physician, and with this step, the situation can become very complicated, particularly for Americans.

The patient reports being sick with the flu for the past 8 days. She has been vomiting several times a day and has been using more than the recommended dose of antacids in an attempt to calm the nausea. She has become severely dehydrated. After fainting at home she was taken to the hospital. An arterial blood gas sample was drawn and then an IV was placed to help rehydrate her.

The patient is a 45 year old man who had GI surgery 4 days ago.  He is NPO, has a nasogastric tube, and IV fluids of D51/2saline at 100 mL/hr.  The nursing physical assessment includes the following:  alert and oriented; fine crackles; capillary refill within normal limits; moving all extremities, complaining of abdominal pain, muscle aches, and "cottony" mouth; dry mucous membranes, bowel sounds hypoactive, last BM four days ago; skin turgor is poor; 200 mL of dark green substance has drained from NG tube in last 3 hours.  Voiding dark amber urine without difficulty.  Intake for last 24 hours is 2500mL.  Output is 2000mL including urine and NG drainage.  Febrile and diaphoretic; BP 130/80; pulse 88; urine specific gravity 1.035; serum

To acquire a baseline of the severity of the nausea, I asked her to quantify it using a verbal descriptor scale (0-10) to establish if it was mild, moderate or severe, which is a recommendation established by the American Society of PeriAnesthesiaNurses (ASPAN). This would allow me to evaluate my interventions to determine if they were effective. The patient stated that she was experiencing a nausea score of "7", which would be moderate to severe in ranking. I immediately assessed the patient, determining that vital signs were stable, no complaints of discomfort, hydration of Lactated Ringers 800 ml was administered, along with prophylactic anti-emetics, Dexamethasone 6mg and Zofran 4mg IVP during surgery. After reviewing the medications ordered for Phase 1 recovery, the only anti-emetic ordered by Anesthesia was a second dose of Zofran 4mg. Based on current literature, it has been determined that when prophylaxis with one has failed, a repeat dose of that drug should not be initiated as a rescue therapy; instead, a drug from a different class of anti-emetic drugs should be administered (SOGC clinical practice). The reason for not repeating the dose is

The first nursing diagnosis based on the finding of my prior assessment would be, impaired urinary elimination, related to multiples causes, which is evidence by frequency, nocturia and urgency. One patient centered intervention would be to avoid any liquids after 6:00PM, and the use of a bedside urinal. The Second nursing diagnosis based on my assessment would be, disturbed sleep pattern, related to multiple causes, which is evidence by the verbalization of difficulty falling and staying asleep, reported fatigue and unsatisfied with the quality of sleep. One patient centered intervention would be, to explore and identify the reasons for sleep deprivation (Lippincott, 2017)

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

In literature from the 2013 eighth edition of Fundamentals of Nursing, the authors express the importance of maintaining the patient’s level of comfort (Potter, Perry, Stockert, Hall, p. 1108). They suggest lubricating the nares often with ongoing care to reduce irritation. Dehydration is a risk for patients who have a nasogastric tube. To reduce the risk of dehydration, the Fundamentals of Nursing states mouth care at least every two hours should be completed. Adena’s current policy differs, with oral care directed at least every four hours. Another method stated to provide comfort includes, turning the patient at regular intervals to reduce abdominal distention (often patients swallow volumes of air) and aid in gastric emptying. The existing

This is essay is going to examine the principles of nursing and health. In order to do this it must look at the concept of health then describe the dimensions that make up health. Secondly, an adult individual will be chosen in order to discuss the determinants that affect their health. It will then go on to explain the underpinning professional, ethical and legal principles that would be taken into consideration if the individual were to require nursing care. Finally, it will identify how carrying out this assignment has informed the writers personal concept of nursing.

Joanna is an experienced nurse taking care of Mrs. Kelly, who was Joanna’s patient many times in the past for her primary problem which is COPD. This time Mrs. Kelly was admitted with complaints of abdominal pain what was different from her primary diagnoses. Her vital signs were with normal limits and no significant changes from privies results, but for the nurse she looks sick, and Joanna know that something is wrong. She calls the resident doctor, but he tell her to watches and calls back with series changes. Joanna multiple attempts to report that something needs to be done to evaluate the cause of Mrs. Kelly pain was ask to calm down. However nobody took patient symptoms series and the next day patient died.