Nursing Process Worksheet Week 2

NURSING PROCESS WORKSHEET Date: _______________________________________________________________________ Student Name: Faculty Name: DR. Thompson Instructions: Each clinical day each student will develop a nursing process outline for one patient of their choice. These are quick writes and should be done throughout the shift and not taken home. These will be discussed in post conferences with the faculty. The outline will be as follows: Assessment (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Obj: Preston Wright is a 73-year old male who was readmitted for a red spot on his sacrum of 1 CM and a 2 CM blister on his right heel. His V/S are as follows: BP, 142/92 Temp, 98.6 F, HR: 160, RR: 23, O2 Sat: 89%. NEURO: Patient is alert and oriented x4 and respond well to touch. His skin color is appropriate for his race. CARDIAC: capillary refill: less than 3sec, no edema noted, S3/S4 heart sounds are present. RESP: Breath sounds are present on all lobes, no present cough or secretions, GI – Bowel sound are normal and active in all 4 quardrants, no abdominal pain or tenderness and his last bowel movent was 11/14. GU – Patient urine is clear and no abnormal smell noted. Mobility – Patient has limited ROM and needs to be reminded to avoid pressure on his heel and sacrum. SKIN – patient is warm and dry to touch. Subj: Patient stated pain at 9/10 and experience some anxiety and dizziness. Nursing Diagnosis (2) Must be prioritized. Must be Nanda using three part statement (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Stem (DX): Etiology (Cause): as evidenced by (Signs and symptoms) Abnormal Assessment Findings. (1) Impaired skin integrity related to mechanical damage of tissue secondary to stress, friction and shea as evidenced by redness and blister on his sacrum. (2) Impaired physical mobility related to loss of motor control and change in mental status as evidenced by patient’s inability to stand without feeling dizziness. Planning (Patient goals) Must be SMART goals Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain) by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.) After 12 hours, patient will be able to ambulate for 30 minutes with a walking aid in order to reduce occurance of pressure ulcers At end of day, patient will be able to manifest signs of healing and verbalize when pain reduces from 9/10 to 3/10. Implementation (Specific nursing interventions that were performed during your shift): Must contain the following: Assess {observe, palpate, percuss}; Monitor; Administer; Collaborate w/ specific multi-disciplinary team; & Teach Page 1 of 3 NURSING PROCESS WORKSHEET      Assess for pain and administer hydrocodone Monitor patient’s vital signs and signs Education on fall precaution Place call-light within patient’s reach Call for assistance when trying to ambulate Evaluation (What was the outcome: Goal; Met or Not met or Partially met and How to revise.) Goal was partially met. The patient was able to ambulate for 30 minutes at the end of the day and did not fall while ambulating to the bathroom. Patient will continue with fall precaution and increase ambulation time gradually. Nursing Application Assessment Include activities throughout the day performed in relation to the following NCLEX content categories. See content category examples below as cited by NCSBN Management of Care Administer medication as ordered by primary care physician, educate patient on medications and the side effects associated with them, monitor the lab results and EKG for any irregularities. Monitor patient for signs of dizziness and fall risk. Safety and Infection Control Educate patient on fall precaution and place call light within patient reach. Keep bed at lowest position and raise the side rails up x3. Advice patient to call for help before ambulating. Ensure to wash hand before and after care to prevent infections. Basic Care and Comfort Assist the patient with their ADLs and encourage the use of ambulatory aid. Keep the patient comfortable by doing pain management as ordered by the physician. Provide privacy and quiet environment to promote relaxation. Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel. Related content includes, but is not limited to: Advance Directives. Advocacy, Assignment, Delegation and Supervision, Case Management, Client Rights, Collaboration with Interdisciplinary Team, Concepts of Management, Confidentiality/Information Security, Continuity of Care, Establishing Priorities, Ethical Practice, Informed Consent, Information Technology, Legal Rights and Responsibilities, Performance Improvement (Quality Improvement), Referrals Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards. Related content includes, but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic Principles, Handling Hazardous and Infectious Materials, Home Safety Reporting of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices Page 2 of 3