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- 125.Which assessment finding would cause the home care RN to revise the plan of carefor the patient who had a total gastrectomy for gastric cancer?Skin turgor is non-tenting over clavicle.Abdominal incision is without redness or drainage.Pain score is 2 when using the 0 to 10 numeric pain scale.Weight loss of 5 pounds in seven days.MAKE SHORT TERM GOAL AND 5 OBJECTIVES FOR THIS DX. Main Dx: Imbalanced nutrition less than body requirements related to Lacto-Ovo vegetarian diet as evidenced by lack of essential minerals & nutrients (Iron, Zinc & Omega Fatty-acids) SHORT TERM GOAL: OBJECTIVES: (ex. after 10 mins, the patient will.. after nursing shift, the patient will.. THE OBJECTIVES ARE ALL ABOUT THE PATIENT.) 1. 2. 3. 4. 5. SCENARIO: Aubrey, 19 years old, an incoming college freshman student went to Ateneo De Manila Health Services for physical examination. The nurse gathered the following information: Height: 5 ft Weight: 48 kg Vital signs: Temp 37.2C, Pulse rate: 95 beats per minute, Respiration rate: 12 breaths per minute, and BP: 100/70mmHg. Family History of illness: Father (+) Hypertension (HPN), and Diabetes Mellitus (DM) Present Health History: Aubrey never experienced to get hospitalized as far as she can remember. Her mother ensures that she takes daily supplemental vitamins such as vitamin…Answer all four questions. The topic is Nutrition Counseling and Dietary Instructions. Note: Make your own choices on what the final diagnosis of the patient so that you will know the diet instructions. Who are qualified to provide dietary instructions What are the preliminary data needed for diet instructions? How will you obtain the preliminary data? How will you prepare the dietary instructional materials.
- MAKE OTHER (5) NURSING DIAGNOSIS RELATED TO THIS DX: proposed dx: Imbalanced nutrition related to lack of knowledge about diet 1. 2. 3. 4. 5. scenario (for more reference): SCENARIO: Aubrey, 19 years old, an incoming college freshman student went to Ateneo De Manila Health Services for physical examination. The nurse gathered the following information: Height: 5 ft Weight: 48 kg Vital signs: Temp 37.2C, Pulse rate: 95 beats per minute, Respiration rate: 12 breaths per minute, and BP: 100/70mmHg. Family History of illness: Father (+) Hypertension (HPN), and Diabetes Mellitus (DM) Present Health History: Aubrey never experienced to get hospitalized as far as she can remember. Her mother ensures that she takes daily supplemental vitamins such as vitamin C and B complex, and every year she gets flu vaccine from their family doctor. During the interview with the nurse, Aubrey mentioned that she has no known allergies. She said “I don’t think I have any problems with my health. I am…Discuss the roles/functions of each member of the health care team in relation to nutrition based on the given situation. Fill out the table provided. Situation: A 45-year-old male stroke patient with right-sided paralysis is admitted to a hospital for nutritional build-up. History revealed that the patient is a former clerk in a law firm and is right-handed. Health Care Team Member Role/Function in Relation to Nutrition 1. Health Care Provider (Physician/Doctor) 2. Nurse 3. Social Worker 4. Physical Therapist 5. Occupational Therapist 6. Speech-Language Therapist 7. Pharmacist 8. Registered Nutritionist and DietitianA nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient’s height is 5′6′′ and his current weight is 325 pounds. What would thenurse document as his BMI?a. 50.5b. 52.4c. 54.5d. 55.2
- Your client, Mrs. O’Bryan has been admitted to room 337 with an admitting diagnosis of an intestinal obstruction. She has had nausea and vomiting since admission with a potential for dehydration. Mrs. O’Bryan voices great anxiety for her job. She is concerned about missing days from her work.(Learning Objectives 2,4, 5) When reviewing the plan of care for Mrs. O’Bryan how would you differentiate the medical diagnosis from the nursing diagnosis? Would there be any potential nursing diagnosis noted for Mrs. O’Bryan? When writing the nursing diagnosis for Mrs. O’Bryan, the nurse must remember to include what three vital elements for all nursing diagnosis? The nurse who understands prioritization of client needs, according to Maslow Hierarchy of Needs, will place what type of client needs as most urgent? Can you identify three nursing diagnosis for Mrs. O’Bryan and how they should be prioritized?List 5-6 post-procedure nursing interventions for a patient that is receiving an upper GI series/Barium swallow test.PLANNING EXERCISES: WRITING GOALS/DESIRED OUTCOMES, NURSING INTERVENTION with SCIENTIFIC RATIONALE Instructions: For each nursing diagnosis (given the scenario), write an appropriate goal with desired outcome, and nursing interventions with corresponding scientific explanation or rationale. Joe Johnson has experienced intermittent nausea for approximately 6 months because of a possible gastric ulcer. He states, “I know I should eat, but when I eat, I hurt.” He has lost 28 pounds since his last annual check-up and weighs less than ideal for his height. His nurse identifies the nursing diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inability to ingest nutrients as a result of biological factors as evidenced by reported food intake less than recommended daily allowance and weight loss of 28 pounds over the past year.
- Case: You are the primary nurse of a 35yo patient who was admitted due to loss of appetite. The patient does not have other diseases (e.g. asthma, hypertension, diabetes). The patient is now on her 3rd hospital day, is already relieved of her primary complaint, and is very comfortable. Below is the vital signs monitoring sheet of the patient for today. Time Temperature (C) Pulse (beats/min) Respiration (respirations/min) Blood pressure (mmHg) 6:00 AM 36.8 88 18 110/70 10:00 AM 37.3 86 18 120/80 2:00 PM 36.5 81 19 110/80 6:00 PM 36.6 83 18 110/80 10:00 PM 36.6 80 17 160/80 Point out the aberrant vital sign What is the possible explanation for this finding? If you are the patient’s nurse, what will be your next step?Which of the following nursing diagnoses would be mostappropriate for a patient with a body mass index (BMI)of 18?a. Risk for Imbalanced Nutrition: More Than BodyRequirementsb. Imbalanced Nutrition: More Than Body Requirementsc. Readiness for Enhanced Nutritiond. Imbalanced Nutrition: Less Than Body RequirementsThe nurse reinforces teaching for a patient after a cholecystectomy who is on a low-fat diet. The nurse will know that the patient understands the diet if which menu items are selected? 1. Roast chicken, rice, gelatin dessert 2. Cream of chicken soup, milk, gelatin dessert 3. Meat loaf, mashed potatoes with small amount of gravy, green beans 4. Turkey and cheese sandwich on whole- grain bread, apple, milk
