Nursing Process Worksheet

Course: NURS 121L-A NURSING PROCESS WORKSHEET Date: ___12/6/2020____________________________________________________________________ Student Name: Faculty Name: 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: Ramona Stukes is a 69-year old Caucasian female who is on her third day post-op following a cholecystectomy. Upon assessment, Her V/S are as follows: BP, 114/62 Temp, 98.6 F, HR: 100, RR: 20, O2 Sat: 94%. NEURO: Patient is alert, cooperative and oriented x4. Her skin color is appropriate for her race. CARDIAC: capillary refill is less than 3sec, no edema noted, S3/S4 heart sounds are present. RESP: Breath sounds are present on all sides of the lobe, no present of cough or mucus secretion. GI: Bowel sound are normal and active in all 4 quardrants, no abdominal pain or tenderness, and her last bowel movement was 12/05. GU – No pain or discomfort during urination and her urine color is yellow with no abnormal smell. Mobility – Patient has limited ROM and can only ambulte with assistance. SKIN – patient skin is warm and dry to touch. Pain: Patient stated pain at 7/10. Subj: Patient stated pain at a level of 7/10 at incision cite and experience some dizziness when ambulating. 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 chemical substance (bile), and stasis of secretion as evidenced redness on incision site and disruption of subcutenous tissue. (2) Acute pain related to post-operative cholesytectomy surgical incision as evidenced by pain scale of 7/10, facial grimace and muscular guarding. 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.) Patient verbalize that pain came down to 3/10 from 7/10 two hours after taking Hydromophone pain medication. At the end shift, patient will be able to manifest signs of healing and ambulate without assistance. 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 Course: NURS 121L-A NURSING PROCESS WORKSHEET Assess for pain and administer hydromophone Monitor patient’s vital signs and symptoms of infection Education on fall precaution Place call-light within patient’s reach Place bedpan under patient’s Evaluation (What was the outcome: Goal; Met or Not met or Partially met and How to revise.) Goal was partially met. Patient was able to verbalize a reduction in pain from 7/10 to 3/10 two hours after taking pain medication Demerol. 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 vital signs and symptons of infection. 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 Course: NURS 121L-A NURSING PROCESS WORKSHEET Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living. Related content includes, but is not limited to: Assistive devices, Elimination, Mobility/Immobility, NonPharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest and Sleep Page 3 of 3