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NURN 215 Nursing Process Assignment

NURN 215 Nursing Process Assignment

NURN 215 Nursing Process Assignment

The Community College of Baltimore County

School of Health Professions

NURN 215

Nursing Process Assignment

Student name ____XX_____________________ Dates of care 12/11/2018 and 12/14/2018____    Points   ________

Patient Initials __G.C___ Date of admission _12/09/2018_____ Age __68M__ Reason for admission ____Excision Left Trochanter Ulcer with Flap Repair___

 

Pathophysiology

 

Define and concisely explain the pathophysiology of the primary and secondary diagnoses or conditions.  Include 4 major signs and symptoms for

each diagnosis. Do not include extraneous information such as incidence, risk factors, predisposing conditions, treatments, etc.  If the diagnosis is

surgical, briefly explain the surgical intervention and the underlying reason for the surgery.  Use a Med-Surg or Pathophysiology textbook.

(Cite Source)

 

 

NURN 215 Nursing Process Assignment

Primary Diagnosis(es): Stage IV Left Hip Ulcer of the Trochanter with flap repair.

Mr. G.C was status post left hip replacement about one year ago. …

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Secondary Diagnosis(es):  Osteomyelitis, Congestive Heart Failure, and Coronary Artery Disease

Osteomyelitis– Bacterial infection of bone and soft Tissue

Signs and Symptoms: Bone Pain, Localized Edema, Redness, and Warmth. Increased Pain with movement.

Congestive Heart failure:…

Coronary Artery Disease: Loss of Elasticity of the Arteries …

(Williams and Wilkins (2008) pg. 25-36)

Nursing Care /Treatments, Rationale, and Related Nursing Concepts:   List the nursing interventions and treatments ordered for the patient.  Explain the rationale for each as it relates to your patient’s diagnoses/conditions.  Identify the nursing concepts and/or threads that relate to the nursing care and treatments.

Nursing Care and Treatments Rationale (Cite Source) Related Concepts and/or Threads
Provide wound care and Monitor Drainage Prevent Infection  
Monitor and Maintain Position Patient unable to lay on the left hip Comfort and Perfusion
Assess Pain Level   Comfort
Monitor for Fluid Overload Prevent exacerbation of CHF Perfusion
Monitor for Fluid Volume Deficient   Perfusion
Monitor for Nutrition Imbalance; less than body requirements    
 Monitor and Record Vital Signs    
Maintain Head of Bed in Semi Fowlers Position
Provide a Cardiac Diet   Perfusion
Reposition every two hours   Perfusion
Assist with Activities of daily Living   Comfort and Infection
  (Williams and Wilkins (2008) pg. 25-36)  
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Medications:

 

Medications

Include medication, dosage, route, frequency, time.

 Reason for Taking

Be specific for your patient.

 Assessment Needed Prior to Giving Medication

This information can be obtained in the Drug Guide under Nursing Implication.

 Evaluation of Effectiveness

To be completed after medications are given.  State how effective each medication was for your patient. Indicate measurable values that show how the medication is working, e.g., vital signs, lab values, patient statement, pain scale, I&0, etc…
1.Ascorbic Acid 500mg PO Daily @ 10:00am Wound Healing Monitor if patient is a Type I diabetic, Cigarette smoker, Alcoholism, and Small Intestine Disorder for Absorption  
2.Carisoprodol 350mg PO TID @0500, 1400, and 2200 Musculoskeletal Pain Tolerance to drug and Renal/Hepatic Impairment Pain level decreased from a to  within an hour with oxycodone.
3. Carvedilol 6.25mg PO BID @ 1000 and 2200 Hypertension Do not stop abruptly and Check Blood Pressure and pulse prior to giving to patient  
4. Furosemide 80mg PO Daily @ 0800 Edema Monitor for hypokalemia Decreased fluid Retention and resolution of edema
5. LamTRIgine 100mg PO TID @ 0500, 1400, and 2200 Tonic-Clonic Seizures Taper when discontinued and SI Prevents Seizure
6. Montelukast 10mg PO Daily @ 2200 Asthma Not for Acute Asthma Attacks and SI Alleviates Wheezing
7. Nystatin Topical 100,000units/g BID @1000 and 2200 Candidiasis of skin GI upset, Steven Johnson Syndrome Decreased redness from the fungal infection
8.Potassium Chloride 10meg PO Daily @ 1400 On Lasix and k+ low on 12/12/2015 (3.4) Monitor ECG and DO NOT GIVE IV PUSH Potassium 3.8 on 12/14/2015
9. Pravastatin 80mg PO Daily @ 2200 Hypercholesterolemia Photosensitivity, Full effect may take up to 4 weeks  
10. Zinc Sulfate 220mg PO Daily @2200 Wound Healing Monitor for fever, chills, and sore throat.  
11. Vancomycin 1.25gm IV BID @0800 and 2000 MRSA Red Man Syndrome. Infuse over 1-3 hours  
12.  Oxycodone 10mg PO PRN every 4 hours Acute Pain Pain Level, CNS status, and Respirations Resolution of pain from a 10 to a 0.

NURN 215 Nursing Process Assignment

Priority Nursing Diagnosis

Using your problem list from your nursing assessment, formulate the 3-part priority nursing diagnosis appropriate to your patient’s condition or needs.

Provide rationale for the selection of this nursing diagnosis as the priority nursing diagnosis.

 Outcome

 

Write a patient centered, measurable, realistic outcome that includes a target date.

 Interventions

 

Select six nursing actions that are appropriate to meeting the needs of your patient, making sure that they relate to the nursing diagnosis you selected.  Be sure that the interventions will help to achieve the outcome that you created.

 Scientific Rationale

 Explain the scientific rationale for each nursing action that you have selected.  (Cite Source)

 Evaluation of outcome

Describe how the patient is progressing toward meeting the outcome. Use both subjective and objective data to help you evaluate your patient’s progress.

 
Diagnosis:

Risk for impaired skin integrity related to physical immobilization AEB bedfast

 

 

 

Rationale:

The patient is S/P left Hip Excision of the trochanter with flap repair. The patient can only reposition on his right side and back. The patient is also bedfast.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Patient will not show evidence of skin breakdown by projected discharge date of 12/14/2015. 1)     Inspect skin every skin, describe and document skin conditions.

2)     Change patients position at least every 2 hours.

3)     Explain the therapy to patient and family members to encourage compliance.

4)     Instruct patient and family members of the skin care regimen to encourage compliance.

5)     Administer pain medication and monitor effectiveness. Patient needs pain relief to maintain comfort and reposition.

6)     Use a foam mattress, bed cradle, or other device to minimize skin breakdown.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sparks, S and Taylor, C. (2011) pg 305

1)     To provider evidence of the effectiveness of skin care regimen.

2)     Provides comfort and minimal pressure on bony prominences.

3)     Patient and family are involved in care and knowledge to prevent skin breakdown.

4)     Increases probability that care will continue beyond hospital admission and prevention of skin breakdown.

5)     Patient will be more compliant with treatment if pain is not a debilitating factor.

6)     Decreases the chances of skin breakdown with the use of assistive devices.

 

 

 

 

 

 

 

 

 

Sparks, S and Taylor, C. (2011) pg 306

 The patient is not progressing towards meeting the expected outcome. The patient is refusing to change positions as recommended and lays predominantly on his right side. Patient has developed erythema on right hip. 

NURN 215 Nursing Process Assignment

Reference Page:

Sparks, S and Taylor, C. (2011) Sparks and Taylors Nursing Diagnosis reference manual (8th ed.) Philadelphia: Wolters Kluwer Health-Lippinott Williams and Wilkins (pg. 305 and 306)

Straight A’s in Medical Surgical Nursing (2nd ed. pp 25-36). (2008). Philadelphia, Pa: Wolters Kluwer Health-Lippinott Williams and Wilkins.