Nursing Assessment, Diagnosis, and Interventions Scenarios

1. Questions about nursing assessment A 28 year old 22 weeks pregnant woman came to the MCH polyclinic for a pregnancy check-up. Results of the study: history of childbirth in 2000 gave birth to a baby boy at 38 weeks' gestation. In 2007 gave birth to another baby boy at 37 weeks of gestation and in 2012 suffered a miscarriage at 12 weeks of gestation. How to write obstetric status in the above case? Before answering, make sure you have studied obstetric status, namely Gravid (G), which is the number of pregnancies, Partition (P), namely birth after 20 weeks' gestation without seeing the baby live or die, and Abortion (A), namely the discharge of conception before the fetus can live outside the womb with gestational age less than 20 weeks. So to write the obstetric status in this case, the correct one is G4 P2 A1 (currently the patient is the 4th pregnancy, has given birth 2 times, and had 1 abortion). 2. Questions determine the problem/nursing diagnosis. A 46 year old man was brought by his family to the polyclinic with the following complaint: shortness of breath. The results of the assessment: left chest pain, cough, the condition of the pain is more severe when walking, the characteristic of intermittent pain. Pain scale 7/10, the patient complains of limited activity, quickly feels tired, on examination of vital signs BP: 190/90 mmHg, pulse rate 112 x/min, temperature: 37 C, respiratory rate: 40 x/min. What is the main problem in the above case? One strategy that can be applied to answer the above question is to look at the dominant data that appears the most in the case above. If we pay attention to the patient's complaint to the health facility is shortness of breath, but when we look at the case description it leads to a problem of pain with left chest pain data, severe pain during activity, intermittent pain, pain scale of 7 and an increase in pulse. So the most appropriate answer in the case above is ACUTE PAIN. 3. The question of determining nursing interventions/actions A 3-year-old child is brought by his mother to the emergency room with shortness of breath and coughing. Assessment results: the child cannot secrete, wheezing sounds, respiratory rate 46x/minute. Her mother seemed worried about her son's condition. What is the main nursing action in this case? To determine the exact answer, we look at the problem that arose in this case, namely that the child experienced shortness of breath due to an accumulation of secretions in the respiratory tract, which was indicated by additional breath sounds, namely wheezing. So to overcome this problem, we intervene to overcome airway obstruction, namely the act of giving inhalation (nebulizer) to loosen the airway (bronchi), a bronchodilator is needed. At the intervention/nursing action stage there are also types of questions related to appropriate procedural actions. Pay attention to this matter: A 47 year old man is being treated in the operating room because of difficulty urinating. The patient had a urinary catheter inserted. After lubricating the catheter with jelly, the catheter is inserted easily and without any obstacles, immediately the urine is seen coming out and collected in a crooked. What is the next action the nurse will take for this patient? To answer questions of this type, make sure we have read or mastered the proper action procedural standards. If we look at the case above, the urine that comes out through the catheter shows that the catheter has just arrived at the urethra, so we need to insert the catheter until it is branched to make sure the catheter has actually reached the bladder, after that we do internal fixation by inserting 0.9 NaCl so that balloon expansion occurs.