nursing process worksheet
Name: Faculty Name: DR.Victoria Ogundeko Date:__ 05/18/2024___________ N121L-A: Nursing Process Worksheet Instructions: Each clinical day, the student will develop a nursing process outline for one patient. These will be discussed in clinical and post-conferences with the faculty. Use the AAPIE Nursing Framework (Assess, Analyze, Plan, Implement, and Evaluate) for your assigned patient to complete the Nursing Process Worksheet. Upload to CANVAS after the conference. 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 Completed YES YES If not, why? YES YES YES YES YES IDENTIFICATION DATA Patient Initials: C. A Age:59 Gender: MALE Allergies: N/A Isolation: N/A Code Status: o Full Code o DNR o Modified: CHIEF COMPLAINT Patient C.A. is a 59-year-old male, presents with increased and persistent abdominal pain localized to the upper right quadrant. ADMITTING DIAGNOSIS Cholecystostomy Tube Malfunction 1 Pathophysiology Instructions: Provide a complete and detailed pathophysiology of the admitting diagnosis. The pathophysiology section must include signs and symptoms, risk factors, and complications. The section must relate back to the patient. Use academic, evidence-based references to support each criterion. A catheter placed to drain the gallbladder in patients who cannot undergo surgery fails to function appropriately during a cholecystostomy tube malfunction (Pabani et al., 2021). This can be due to obstructions caused by thick bile, sludge, stones, tube displacement, infection, kinking, or biofilm deposition. When the device fails, and the pressure rises in the gallbladder, the pain increases, especially the pain felt in the upper right quadrant, as was the Pathophysiology of Admitting Diagnosis case with patient C. A. Other possible symptoms are fever, chills, and sepsis if an infection develops. Treating this condition requires repositioning or replacing the catheter, flushing it to clear the blockage, administering antibiotics for infection, and giving analgesics for pain relief. Regular control is necessary to make sure the tube works and a patient’s recovery (Pabani et al., 2021). When the cholecystostomy catheter is not functioning properly, the patient often experiences a spectrum of symptoms. Abdominal pain of the right upper quadrant is a typical presentation and is mostly associated with tenderness and guarding (Pabani et al., 2021). Fever and chills can be an indication of infection, Signs & Symptoms as rapid heart rate, low blood pressure, and altered mental status are symptoms of sepsis, which is more dangerous due to the systemic response. Further, leaking of the drainage or lack of bile in the collection bag suggests possible blockage or movement of the tube. This symptomatology requires urgent medical attention in order to avoid secondary consequences. 2 Risk factors for the malfunction of the cholecystostomy tube are as include advanced age, severe comorbidities, and a history of gallbladder disease or previous abdominal surgery (Cheeyandira, 2020). This risk group of patients is more likely to develop complications with the function of the tube as they are Risk Factors also comparably weak and slow in healing. Furthermore, factors that encourage thick bile production or make bile sludge and stones more likely can also cause the tube to become blocked. Besides nutritional deficiency and immunodeficiency, potential tube-related problems can also be exacerbated. Complications resulting from cholecystostomy tube malfunction are potentially severe and include obstruction, displacement, infection, and bile leakage. Blockage can be caused by thick bile, sludge, or stones passing through the tube, while displacement results from patient movements or wrong tube placements. Complications Infection is a severe disease; this tube could allow bacteria to enter and cause cholecystitis or sepsis (Gulaya et al.). The spillage of bile into the abdomen will compromise the integrity of the abdominal wall and may lead to peritonitis, which is a potentially fatal condition. These problems require quick diagnosis and therapy to prevent aggravation of the patient’s condition. The malfunctioning cholecystostomy tube in patient C. A. is the primary cause of his current symptoms and condition. The tube’s foremost function is to drain bile from the gallbladder, relieving pressure and preventing contamination. But Describe the relationship between the pathophysiology in some cases, an obstruction, displacement, or infection of the drainage duct and the patient’s current may be why the bile is not properly drained. This will lead to elevated condition in your own words (does not need citation) intragallbladder pressure and inflammation, which will eventually cause severe upper right quadrant abdominal pain, together with tenderness and guarding upon physical examination. Poor drainage can be a source of bile leakage, 3 which could lead to conditions like peritonitis and systemic infection and might explain why patient C. A.’s symptoms are as severe as they are. Therefore, rectifying the problem quickly is the best way to relieve his pain and avoid other medical problems. CURRENT VITALS AND DATA HR: 59 R.R.: 17 breaths/min Pain: 7/10 Height (inches): 67 Temp:98 BP: 119/70 SpO2: 98 Weight (lbs.): 169 ANALYSIS OF ASSESSMENT CUES Instructions: In the space below, enter both subjective and 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 WNL or Abnormal List of Abnormal Assessment Cues Explanation of Abnormal Assessment Cues with Evidence-based Citations Neuro WNL None N/A Cardio WNL None N/A Although the respiratory system is currently normal, Resp WNL None close monitoring is necessary due to the risk of infection spreading from the abdomen, 4 which could lead to respiratory complications (Gulaya et al.n.d). The malfunctioning G.I. Abnormal – Increased and persistent cholecystostomy tube causes abdominal pain in the upper bile to accumulate, leading to right quadrant- Abdominal increased pressure and tenderness and guarding- inflammation, which manifests Pain intensity reported as 7/10 as pain and tenderness (Gulaya et al., n.d) GU WNL None N/A Skin WNL None N/A Mobility WNL None N/A Safety WNL None N/A Psych-Soc WNL None N/A Effective pain management is crucial, as unmanaged pain can Pain Abnormal – Reports pain intensity as 7/10 lead to increased stress, delayed recovery, and decreased quality of life. (Gulaya et al., n.d) 5 PRIORITY HYPOTHESIS/PROBLEM Using the pertinent abnormal cues, choose one priority hypothesis The category hypothesis is that Patient C. A.’s abdominal pain and tenderness at the upper right quadrant, as well as the guarding in the region, are indications of cholecystostomy tube malfunctioning, which is (the primary cause) leading to biliary stasis and possible infection. SMART GOAL The goal must be Specific, Measurable, Attainable, Realistic, and Timestamped. Start the goal statement with, “Patient will… by…” It is expected that Patient C. A. will experience a decrease in pain intensity that will go from 7/10 to 3/10 (or less) within the next 24 hours by the implementation of pain management interventions, just as it would be the case with the administration of analgesics and evaluation of the cholecystostomy tube function. IMPLEMENTATION For the identified priority hypothesis/problem, provide four independent interventions (1 must be a teaching intervention). All interventions must have a rationale supported by evidence-based citations. 1. Administer Analgesic Medication Rationale: Pain relief is an essential aspect of patient care as pain relates to their comfort and general wellbeing (Wells, 2023). Administering analgesic medications, including acetaminophen or opioids, as it is necessary, can help to lessen Patient C. A.’s degree of pain from 7/10 to no more than 3/10 or less within one day, which is what is specified in the SMART goal. Research has shown that good pain relieving methods can lead to positive health outcomes such as faster recovery and reduced healthcare bills. 2. Evaluate Cholecystostomy Tube Function Rationale: The evaluation of the cholecystostomy tube’s functionality includes an examination of any obstructions, misplacements, or malfunctions that may be linked with Patient C.A.’s condition. This can help to avoid cholestasis and stagnation of bile and, consequently, infection. Identifying the problematic areas of the tube and addressing them in early detection as well as intervention will help to achieve better patient results and have minimal complications (Fahrbach, 2024). 6 3. Monitor Vital Signs and Abdominal Examination: Rationale: Relentless monitoring of vital signs such as pulse, respiratory rate, temperature, blood pressure, and oxygen saturation through abdominal examinations now and then helps to pick up changes in Patient C. A. condition. Abnormal vital sign or gradually worsening pain in the abdomen can indicate worsening septic condition or peritonitis, which requires immediate intervention (Panwar et al., 2021). 4. Provide Patient Education on Signs of Infection and When to Seek Medical Attention: Rationale: Patient education plays a crucial role in promoting self-management and early detection of complications. Educating Patient C.A. on signs of infection, such as fever, chills, increased pain, or changes in abdominal tenderness, empowers him to recognize and report symptoms promptly, facilitating timely medical intervention and preventing potential complications (Patrick et al., 2017). EVALUATION Select whether your goal was met, partially met, or not met. If goal was met, explain why. If the goal was partially met or not met, it must include revisions. o Goal Met Why the goal was met: The set objective was achieved as there was a remarkable change in the patient’s condition. This was demonstrated by a substantial reduction in pain intensity from 7/10 to 3/10 or lower within the allotted period. The administration of pain medications, evaluation of straw function, close monitoring of vital signs, and belly examination all played a part in the good outcome. The patient education related to structural infection markers and self-care measures also provided a significant helping hand in this case. Taking into account this achievement, I will continue to highlight the evidence-proven methods and patient education so that patient care will be as optimal as possible and the patients will feel better. o Goal Partially Met Revision(s): 7 o Goal Not Met Revision(s): 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 are provided to the patient to help with disease or medical problem/s 1. Managing Patient C. A.’s care precisely with every detail being paid attention to is the best method for better outcomes. It requires teamwork, whereby healthcare professionals, such as physicians, nurses, and specialists, work together to develop a customized care home plan that is based on the patients’ needs. Through constant monitoring of the patient’s condition, response to treatment, and vital signs, we are able to make prompt adjustments to the plan of care according to new information and changes being observed (Patrick et al., 2017). Furthermore, working together with the patient and his or her family promotes collaboration and guarantees care is provided according to their preferences and beliefs during the care process. Through ensuring coordination, assessment, and communication, the aim of management of care is to provide the kind of care that is both patient-centered and holistic, safely effective, and aids in recovery. Safety and Infection Control Measures done to keep the patient and you safe, to prevent infection and worse condition 2. Safety and infection prevention are integral parts of nursing care, particularly for patients like C. A., who can develop complications much more easily. These steps to guarantee a safe environment involve having enough lighting, clearing the clutter, and incorporating prevention of falls, such as using bed rails and assisted ambulation (Mehta et al., n.d). Implementation of infection control procedures, which include hand hygiene, the right way to use personal protective equipment, and being in isolation whenever necessary, minimize the risk of healthcare-associated infections. A routine of environmental cleaning and disinfection is therefore additionally implemented to prevent the transmission of pathogens. 8 Basic Care and Comfort Nursing measures given to patients to keep them clean and comfortable 3. The groundwork of nursing support, which involves the physical and emotional state of the patient, is built on care and comfort. The main goal of nursing interventions is to help the patients fulfill their primary needs by providing care, both technical and non-technical ones, such as bathing, getting clean after using the toilet, etc. Maintaining a clean, comfortable environment helps the patient obtain adequate sleep and, in turn, promotes recovery. Along with this, the emotional support, active listening, and therapeutic communication provisions also nurture the feeling of trust and security, thereby decreasing the level of anxiety and providing a positive experience for the patient. 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 Teams, 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, Non-Pharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, and Rest. STUDENT JOURNAL Personal goals for the day What clinical objectives did you focus on today? 9 Today, my goal was not to be negative and to use empathy whenever possible. Listening carefully, giving support, and speaking up for their needs were my goals in order to improve their experience during their stay at the hospital. Furthermore, I fully accepted taking care of myself and living a harmonious life that would provide me with energy and efficiency all day. At my present clinical practice, I have done my best to achieve several considerable clinical outcomes. Such activities include the assessment of patients ‘ vital signs, the monitoring of the patients ‘ response to the treatment prescribed and ensuring that the patients adhere to the schedule of medication administration. I also focused on preventing such infections by ensuring the use of hand hygiene, personal protective equipment in the correct manner, and other infection control measures. Furthermore, I also worked hand-in-hand with my multidisciplinary teammates to develop a responsive and effective plan for patient care-related problems. Experience (specialty areas) and activities of the day What new skills or procedures did you witness or participate in/assist with? I have been involved in many hands-on practices and techniques related to my field of study. At the same time, I assisted with wound care management, including dressing changes and the assessment of wound healing progress under the direction of the senior nurses. Also, I realized, supported, and took part in nasogastric tube insertion and enteral feeding procedures, which gave me a chance to enhance my practical skills in gastrointestinal nursing care. Not only that, I took part in patient education clinics where I provided them with information about post-discharge care instructions and medication management in order to have them better comprehend and comply with the treatments given. Thoughts about your experience today How did you meet your goal? Do you have any preconceived notions that have changed? 10 Looking back, I have fulfilled my personal goals of providing patients with committed caring and sustaining them through their medical treatments. I am convinced that by listening closely to the anxieties of others and dealing with their problems, I can facilitate a better journey for patients and develop a successful therapeutic relationship with them. Secondly, observing patients showing strength and courage in defeating their health complications was a factor that reemphasized the need for empathy and resilience in nursing. I managed to confirm my ideas about patients and the power of compassion as a tool in the hands of a doctor, as well as my own dedication to patient-oriented care. What are your feelings about today? How can you utilize your experience in the future? Today’s experience has truly left me inspired and spurred me to remain persistent in successful nursing practices. I deeply understand the importance of feeding my clinical abilities and knowledge from the resources around me, which will always be a part of my progress. In the future, I will incorporate those lessons today to ensure my medical practice is patient-oriented, with a caring approach, and finally, teamwork. By incorporating these in my practice, I aim to improve patients’ lives and to raise the quality of health care not only for my specialty area but also overall. 11 References Cheeyandira, A. (2020). Laparoscopic cholecystostomy tube placement. MOJ Clinical & Medical Case Reports, 10(3), 70–72. https://doi.org/10.15406/mojcr.2020.10.00346 Fahrbach, T. T. (2024, February 16). Percutaneous cholecystostomy technique. Percutaneous Cholecystostomy, Complications. https://emedicine.medscape.com/article/1828091-technique Gulaya, K., Desai, S. S., & Sato, K. (n.d.). Percutaneous cholecystostomy: Evidence-based current Clinical Practice. Seminars in interventional radiology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5088094/ Mehta, Y., Gupta, A., Todi, S., Myatra, S., Samaddar, D. P., Patil, V., Bhattacharya, P. K., & Ramasubban, S. (n.d.). Guidelines for prevention of hospital-acquired infections. Indian Journal of Critical Care Medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963198/ Pabani, A., Nithiananthan, S., Mower, B. C., Oppat, W. F., Patil, S., & Jacobs, M. J. (2021). Is partial cholecystectomy a better alternative to percutaneous cholecystostomy tube placement? A populationbased outcomes analysis of partial cholecystectomy and percutaneous cholecystostomy tube placement in 20,141 patients with acute cholecystitis. Journal of the American College of Surgeons, 233(5). https://doi.org/10.1016/j.jamcollsurg.2021.07.296 Panwar, M., Gautam, A., & Acharyya, A. (2021). PPG-based non-invasive methodologies for pervasive monitoring of vitals: B.P. and H.R. Wearable/Personal Monitoring Devices Present to Future, 87–99. https://doi.org/10.1007/978-981-16-5324-7_3 Paterick, T. E., Patel, N., Tajik, A. J., & Chandrasekaran, K. (2017, January). Improving health outcomes through patient education and partnerships with patients. Proceedings (Baylor University. Medical Center). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5242136/ Wells, N. (2023). Improving the quality of care through Pain Assessment and Management. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. https://www.ncbi.nlm.nih.gov/books/NBK2658/ 12
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