Nursing Question
Name: Mary Dzhanoyan_ Faculty Name: Kier Tuazon Date:05/03/2024________________ N101L: Nursing Process Worksheet Instructions: Each clinical day, the student will develop a nursing process outline for one patient of their choice. These will be discussed in clinical and in post-conferences with the faculty. Use the AAPIE Nursing Framework (Assess, Analyze, Plan, Implement, and Evaluate) for your assigned patient to complete the Patient Profile Database Worksheet and the Nursing Process Worksheet. Upload to CANVAS after the conference. (Please use a different color for your data. Choose one color that is easy to read: don’t use GREEN, YELLOW, BLACK. Keep your font style and size consistent throughout.) *Blue will be the information you will need to complete this assignment using Nathan P. Walker in EHR Tutor. DIRECTIONS What needs to be done: Receive Handoff Report Complete Head-to-Toe Assessment Review patient chart: o History and Physical o Progress Notes o Laboratory and Diagnostic Tests o Vital Signs o Medications IDENTIFICATION DATA Patient Initials: NPH Allergies: Peanut Completed X X If not, why? X X X X X Age: 80 Gender: Male Isolation: Code Status: o Full Code o DNR o Modified: CHIEF COMPLAINT ADMITTING DIAGNOSIS HISTORY OF PRESENT ILLNESS (HPI) PERTINENT PAST MEDICAL HISTORY (PMH) 1 Pathophysiology Instructions: Provide a complete and detailed pathophysiology of the admitting diagnosis. Must include signs and symptoms, risk factors, and complications. Must relate the pathophysiology section back to the patient. Use academic, evidence-based references to support each criteria. The one main Medical Diagnosis; this will need at least 2-3 paragraphs of the detailed pathophysiology of the admitting diagnosis. You must use an academic, evidence-based reference to support the information. Pathophysiology of Admitting Diagnosis Signs & Symptoms • • • • • • • Risk Factors (My reference in APA format, year). (Tuazon, 2023) (Tuazon & Funakoshi, 2023) (Tuazon et. al, 2023) (CDC, 2024) You may use bullet points for the Signs & Symptoms If the reference is different from above Use another APA format reference at the end of each row (My reference in APA format, year). Same for risk factors, you may use bullet points. Use APA format, if a difference reference is used, do not forget to add the citation in each box (My reference in APA format, year). • Complications Describe the relationship between the pathophysiology and the patient’s current condition in your own words • • You may use bullet points for the complications. Use APA format, if a difference reference is used, do not forget to add the citation in each box (My reference in APA format, year). This is where you start to corelate the pathophysiology and the patient’s current conditions in your own words. Do not use a citation, as this is in your own words. (does not need citation) 2 CURRENT VITALS AND DATA HR: RR: Pain: Height (cm): Temp: BP: SpO2: Weight (kg): *if unable to find ANY information, use an expected range. ANALYSIS OF ASSESSMENT CUES Instructions: In the space below, enter both subjective & objective data for all body systems gathered during your client assessment. Identify the top 3 priority body systems containing the assessment cues with cited explanations in relation to the patient and admitting diagnosis. Body System (ALL gray boxes in this column must be filled) *if unable to find ANY information, use an expected range for this patient. EACH GRAY BOX MUST BE FILLED OUT Explanation of Abnormal Assessment Cues with evidence-based citations WNL or List of Abnormal Abnormal Assessment Cues (All boxes will (ONLY the abnormal findings (Choose 3 priority body need to be need to be listed in this systems based on your identified as column) abnormal assessment cues. WNL or Explain why this abnormal, Abnormal in this YOU WILL NEED A column) CITATION from where you obtained the information) 1-2 sentences or bullet points is acceptable. O: Objective data S: Subjective data Neuro What neuro assessments need to be done? Alert and oriented x4 PERRLA No extraocular eye movements No facial dropping Speech is clear and able to articulate WNL or abnormal Why is it abnormal? WNL WNL WNL Is this a priority? Yes: explain why with citation No: Skip and put “n/a” N/A WNL WNL 3 Cardio Which other cardiac assessments do you need to do? Resp GI Inspect: round and distended Auscultate: Absent in all quadrants Percuss: tympany Palpate: Firm, tender LBM: 4 days ago Abnormal Normal is nondistended Abnormal Normal bowel sings are between 5-30 sounds per min WNL Abnormal Abnormal 1.Why is this important? 2-3 sentences Citations Normal should be soft and nontender Patient is constipated GU Skin Mobility Safety Psych-Social Pain 4 5 ANALYSIS OF TOP 3 LABORATORY DATA/DIAGNOSTIC TESTS Lab/Diagnostic Test Date Reference Range (Choose 3 labs/diagnostics Date of Reference that are pertinent range/expected to the patient’s findings diagnosis). Use the 2 below: CBC BMP Result Results from the patient’s chart Date of Reference range: Results from patient’s chart WBC: WBC: Hemoglobin: Hemoglobin: Hematocrit: Hematocrit: Platelets: Platelets: Date of Reference range: Results from patient’s chart Sodium: Sodium: Chloride: Chloride: Potassium: Potassium: CO2: CO2: BUN: BUN: Creatinine: Creatinine: Glucose: Glucose: Why is this test necessary in relation to the patient’s admitting diagnosis? Use citations. Why is this test necessary in relation to the patient’s admitting diagnosis? More than 1 sentence. Do not write. It checks for pneumonia. Use citations. Why is this test necessary in relation to the patient’s admitting diagnosis? Use citations. Why is this test necessary in relation to the patient’s admitting diagnosis? Use citations. XR Left Hip 6 MEDICATION LIST *May use smaller font (no smaller than 9). Complete ALL the boxes. Class Purpose Medication – Pharmacological (pertinent to Generic / Trade – Therapeutic patient) *INCLUDE both GENERIC and TRADE names Metoprolol Beta Blocker (Lopressor) Antihypertensives Dose/Route/Time (Frequency) This info. Will be from the patient’s chart Hypertension Angia Prevention of MI Regular Insulin Pancreatic Antidiabetics, hormones Control of hyperglycemia NPH Insulin Pancreatic Antidiabetics hormones Control of hyperglycemia Colace Stool softeners Laxatives Prevent constipation Mechanism of Action Common Side Effects Looks this up in drug Look this up in drug book book Nursing Considerations Look this up in drug book (Citation, year). Slows down heart rate and contractility Heart Failure Monitor HR&BP Fatigue Take medications as Bradycardia directed Pulmonary Edema Lowers blood glucose Confusion weight gain Monitor body weight by stimulating loss of appetite assess patients glucose uptake in drowsiness periodically for skeletal muscle and symptoms of fat inhibiting hepatic hypoglycemia glucose pro duction Lowers blood glucose Headache anxiety Assess patients by stimulating weakness tachycardia periodically for glucose uptake in symptoms of skeletal muscle and hypoglycemia fat inhibiting hepatic glucose pro duction Promotes Nausea stomach pain Do not administer incorporation of diarrhea vomiting within two hours of water into stool, cramps other laxatives resulting in softer tablet/solution should fecal mass. be taken with water Vallerand Sanosik (2023) 7 PRIORITY HYPOTHESIS/PROBLEM Using the pertinent abnormal cues, choose 1 priority hypothesis The priority problem is the patient is at risk for dehydration because he is nauseated, he is unable to eat due to his bowel sounds decreased and an admitting diagnosis of small bowel obstruction. Do Not Use a medical diagnosis for this hypothesis/problem. SMART GOAL Goal must be Specific, Measurable, Attainable, Realistic, and Timestamped. Start goal statement with, “Patient will… by…” The above is my goal for the patient and it correlates to the problem I have identified as a top priority. The patient may have several problems: no insurance, decrease in mobility, pain to his abdomen, etc… but I am going to focus on the nausea for my goal. For it to be SMART I must answer: Is this Specific? Yes Is this Measurable? Yes Is this Attainable? Yes Is this Realistic? Yes Is this Timestamped? Yes IMPLEMENTATION For the identified priority hypothesis/problem, provide 4 independent interventions (1 must be a teaching intervention). All interventions must have a rationale supported by evidence-based citations. *These are the actions you will take to support your SMART goal. They must be related to the SMART goal. For example, it is not appropriate to have an intervention about pain, insurance, or smoking; unless those are causing his nausea. 1. Assess the patient’s ____ every __ hours. Rationale: You will need to find a rationale to support this intervention and provide an evidence-based citation (Citation, year). 2. Administer prescribed _____PRN for _______. Rationale: You will need to find a rationale to support this intervention and provide the evidenced-based citation (Citation, year). 8 3. Place ______ per md order. Rationale: You will need to find a rationale to support this intervention and provide the evidenced-based citation (Citation, year). 4. Instruct the patient to___________. (ONE INTERVENTION MUST BE A TEACHING INTERVENTION) Rationale: I will need to find a Rationale to support this intervention and provide the evidenced-based citation (Citation, year). EVALUATION Select whether your goal was met, partially met, or not met. If goal was met, explain why. If goal was partially met or not met, must include revisions. o Goal Met Why the goal was met: Goal was met because patient ______ throughout this shift. o Goal Partially Met Revision(s): *If goal partially met you will need a new SMART goal. o Goal Not Met Revision(s): *If goal not met you will need a new SMART goal. 9 NURSING APPLICATION ASSESSMENT Instructions: Include activities throughout the day performed in relation to the following NCLEX content categories. See content category below for examples from the NCSBN. Management of Care Nursing treatments provided to patient to help disease or medical problem/s See below for the definitions to fill out this section. List any nursing treatments provided for this patient under the Management of Care (at least 2). Delegate Safety and Infection Control Measures done to keep patient and you are safe, to prevent infection and worse condition See below for the definitions to fill out this section. List any nursing treatments provided for this patient under the Management of Care (at least 2). Ergonomic Principles: kfsjd;fjsd;fjsd;lfs Basic Care and Comfort Nursing measures given to patient to keep clean and comfortable See below for the definitions to fill out this section. List any nursing treatments provided for this patient under the Management of Care (at least 2). DEFINITIONS OF ABOVE 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, Managing 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 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 10 STUDENT JOURNAL Personal goals for the day What clinical objectives did you focus on today? My personal goal for today was to finish all my homework assignments by midnight. I was able to turn in everything by 11:30!!! My clinical objective for today was to practice head to toe. I watched head to toe videos on canvas and was able to get a better understanding. Experience (specialty areas) and activities of the day What new skills or procedures did you witness or participate/assist with? I got good practice on my head part for the head-to-toe. I got a better understanding on the auscultations for head-to-toe and where I have to place my stethoscope. Thoughts about your experience today How did you meet your goal? Do you have any preconceived notions that changed? I was worried that I was going to procrastinate my homework assignments and I didn’t! I’m happy I reached my goal and didn’t get lazy. Your feelings about today How can you utilize your experience in the future? I am happy I got my assignments over with! Now I can focus on studying for my funds 100 test and practice my head-to-toe. 🙂 11 References APA 7th edition format. This is a separate page. Have at least 4 references: 1 for the pathophysiology, 1 for the medications, 1 labs/diagnostic tests, and 1 for the nursing process (AAPIE). Remember the reference page includes the hanging indentation and is alphabetized. Pendix, A. (2023). Do not put the month on there. Zon, A., Morrow, J., & Doe, K. (2023). Please make all the fonts and colors the same: Make everything look uniform. West Coast University. https://doi.org/1234566.8901234 Common Mistakes Missing in-text citations or not put in the correct spots (doubled up) or (more than the year/webpage). APA reference page was not indented; some had quotes “” Missing title of instructor More than 13 pages Too much info/not enough info. Meds missing trade/generic: more than 6 for NPW Did not use Ama Zon: left Abe Pendix Missing boxes/ spelling Personal Student Journaling 12
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