NUR 153 Nursing Process Assignment F13

NUR 153 Nursing Process Assignment F13

NUR 153 Nursing Process Assignment F13

Nursing Process Quiz

Student Name: ________________

Directions:  Read the following vignette and the write one actual and one risk nursing diagnosis for the patient in the vignette. Write one outcome statement for each nursing diagnosis. The outcome statement should reflect the diagnosis, be patient centered, be measurable and have a time frame. Write one intervention for each nursing diagnoses. The intervention should be clearly written so anyone could follow your care plan and should also have a time frame for how often it should be done. Use the Ackley & Ladwig Nursing Diagnosis Handbook for reference.

Vignette: Mr. Knight, a 62-year-old male, had surgery for a compound fracture of his left lower leg, which happened when he fell from a ladder. The open wound was contaminated with dirt and debris and he sustained a large blood loss before the paramedics arrived. The wound was flushed with sterile saline and an antibiotic solution. A cast was not applied to the leg, rather an external fixation device (pins extending through the skin and bone) was inserted to immobilize the tibia and fibula. The device is heavy and awkward making it difficult for Mr. Knight to move and he winces and moans with pain upon movement. He is to remain on bedrest for 24 hours. Although there is no evidence of infection, intravenous antibiotics are to be administered every 4 hours.
NUR 153 Nursing Process Assignment F13

1. Nursing diagnostic statement (Actual, 3 part statement):

Impaired physical mobility r/t external fixation device a/e/b wincing and moaning in pain upon movements.

Outcome: The patient will verbalize a decrease in pain level by time of discharge.

 

Intervention: Monitor the patients pain and treat with medicine every 4 hours around the clock for 48 hours.

2. Nursing diagnostic statement (Risk, 2 part statement):

Risk for infection r/t surgery

Outcome: The patient will not have any infection signs and symptoms by time of discharge.

Intervention: Keep patients dressings clean and dry— change daily or as needed.

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