Adpie Examples

CHARACTER ASSESSMENT DATA NURSING DIAGNOSIS PLANNING The Tin Man Middle aged male Cold body, silver skin tone No hair Average height Stiff joints, pt states “rain makes his joints rust” Pt states he “wasn’t given a heart” Irregular chest and/or heart sounds Impaired ROM and physical ability AEB rusting in place and stiff joints Pt will be given fluids (oil) twice daily patient will be taught the importance of oiling himself regularly Situational low self-esteem r/t not being perfect since he wasn’t given a heart Impaired swallowing AEB being rusted shut and his inability to speak The Scarecrow Middle aged male Unkempt clothing Yellow straw-like hair Nose has discoloration, overall skin tone is yellow, skin appears leathery Pt is average height Risk for impaired liver function r/t possible liver failure AEB yellow skin-tone Impaired skin integrity AEB black Pt will be ambulated and engage in physical activities to improve ROM IMPLEMENTATION INTERVENTIONS Pt was oiled/given fluids in AM and PM Pt learned how to oil himself EVALUATION Pt’s ROM has improved Pt did physical activities for 30 mins with NAP Get results from EKG/ECG, review vitals Auscultate heart, labs for heart, need HR, BP, and pulse rates Pt will need a hepatic panel to test liver function Biopsy of discolored skin on naris Pt will be Pt blood work sent to lab to evaluate hepatic function Biopsy sent to lab for review Neurologist evaluated pt. Pt will not need to be reoriented 2 days after Pt’s balance has been improving steadily Pt is not oriented x3 most days Pt has The Lion Pt’s gait is unbalanced without support Pt is very confused and states he “doesn’t have a brain” discoloration of skin on nose referred for a neurological exam Risk for Pt will do impaired physical cognition r/t therapy 2-3 confusion AEB “I times a week have no brain” to improve balance Risk for impaired physical ability r/t sedentary lifestyle AEB being nailed to the post seeing a neurologist. Middle aged male Excessive hair all over body, but it is groomed, shiny, and healthy Pt appears very anxious d/t constant tail flicks and the way he clutches tail for security. Pt is also aggressive Appears to be very saddened d/t statement that his “life has been simply unbearable” Pt hasn’t slept properly and mentions his eyebags Labile emotional control Pt’s therapy appointments have been scheduled. Patient will not be aggressive towards people/healthcare staff Insomnia possibly r/t the anxiety pt exhibits as evidenced by “I am a coward” Chronic low self-esteem AEB he “is a coward” Pt will be referred to therapist to discuss emotional issues and low self-esteem twice a week Pt will meditate and exercise 4 times a week to improve sleep patterns, and if necessary take melatonin Physical therapist saw pt. Pt will be able to walk with assistive equipment after 3 sessions with physical therapist. Pt has started exercising and meditating before bedtime. Pt will get at least 6 hours of sleep each night. balanced gait with assistive equipment. Pt’s emotional state is being stabilized. Pt has not shown unnecessary aggression towards people/health care staff. Sleep pattern has been improved. Pt has slept for 67 hours each night. Wicked Witch of the West Middle aged female Green skin with long curved fingernails Large mole on face Hunched back Raspy voice Angry d/t sister’s recent death Threatening and obsessed with taking revenge on Dorothy Impaired gas exchange d/t clubbed fingernails Risk of kyphosis r/t body stature AEB hunched back Ineffective impulse control AEB ineffective grieving death of sister by blaming Dorothy Pt needs spO2 sat to be taken to determine if there’s impaired gas exchange Pt will be referred to orthopedics for hunched back structure Pt’s spO2 was taken and documented. O2 levels will be stable and within normal range (95-100%) Pt’s O2 levels have not dropped below 95% Pt has appointments scheduled with orthopedics and with grief counselor. Grief counselor will help pt to no longer blame Dorothy for her sister’s death after 4 sessions. Pt’s grieving is progressing in a healthy way. Pt no longer blames Dorothy Pt referred to to grief counselor Assessment: What do you notice about the characters? What color are the characters? How would you describe the character’s joints? Voice? Hair? Mobility? What does the character state? Diagnosis: Using your nursing diagnosis book, write a nursing diagnosis using the correct format in the text. Pick an approved nursing diagnosis from the text that most closely fits the assessment data of the character. Do your best, the purpose is to familiarize yourself with analyzing your assessment data. Planning: Once you have assessed and analyzed/diagnosed, you are now ready to formulate goals for the client. Write two short term goals for each character. The goals should be clear, concise, and measurable. What do you think will benefit the client? What is the client’s goal? Is the goal realistic? Implementation: This is the doing/action phase of the process. What nursing interventions are needed to accomplish the goals you created in the planning phase? You can use your text for ideas. Evaluation: How will you know that you accomplished your goals? Remember the nursing process is cyclical so this phase involves re-assessment. Maybe your goal was unrealistic? Maybe your goal was accomplished? What kept you from reaching your goal? Maybe you need more time to evaluate?