Nursing Fundamentals: Caring and Clinical Decision Making - Assignment Example

Hlten503b Contribute to Client Assessment and Developing Nursing Care Plans Name Institution Date Hlten503b Contribute to Client Assessment and Developing Nursing Care Plans 1 Name: Sylvia, Age: 23, Sex: female, Admit Service: Nursing, Doc: Admission date: 25/09/2012 at 6.00 pm Power of Legal Representative ___ Nurse in Charge: ______ (name/phone) ________My phone: ____ VS 1 Temperature 34.9 °C Blood pressure P 110/58 Heart Rate 79 RR 19bpm SaO2 94% VS 2 Temperature 34.9 °C Blood Pressure Lying 110/60 Blood Pressure Standing 90/40 Heart Rate 134 RR27bpm SaO2 94% Current medications: 400 Meg of Narcain Specimens ordered: Blood specimens; FBE, U and E Integementary: extremely pale; veins on her middle arms are scarred. IV access was placed in her foot Central Nervous System: Current Temperature is 34.9. Sylvia is orientated & aware, has lower abdominal pain having a scale of 10. She is insulting but can follow any instructions. Her movement is limited because of the abdominal pain. Pupil scale is 2, because of latest heroin use FBE, U&E: She is tachycardic; the rate of her heart beat has risen from 79 to 134. Sylvia’s BP is 110/60 lying, 90/40 standing, her BP on arrival was 110/58 CvS: Sylvia vomited, blood stains within sputum, upon admittance into the GI ward. She has Hepatitis C, according to her history she is not HIV psitive.IV in foot, 22 gauge Digestive system: Sylvia vomited after being admitted. Her breath smells of alcohol. She is emaciated nevertheless are no mouth orders Renal system: Sylvia has constipation and this is due to her heroin addiction. Her urine is offensive and discolored from drug and alcohol usage. (Daniels, 2008). IV Site: Foot Present medications: 400 Meg of Narcain Specimens ordered: Blood specimens; FBE, U and E Other examinations: TBA (Abdo X-Ray, Abdo U/S, Head and Abdo CT). Notes Sylvia, a 23 year old lady was admitted to the hospital on 25/09/2012 at 6.00 pm with problems with Central Nervous System, heart problems, respiratory, CvS, Digestive system, renal system as well as musculoskeletal system problems. She is jobless and has been abusing alcohol and drugs for a long time and was found unconscious in a pathway. She was administered with a 400 Meg of Narcain by the ambulance staff at the location and arrived at the Emergency Department swearing at every person and being offensive. Emergency Department placed an IV access on her foot, and performed a CXR. Her medical history includes Hepatitis C but is HIV negative. Her condition has worsened because previous observations were Temperature 34.9 °C, HR 79, Respiratory Rate 19 bpm, Blood Pressure 110/58 and Sa02 94%. However, when she was being admitted, the observations were Temperature 34.9°C, Heart Rate 134, Respiratory Rate27bpm, Blood Pressure Lying 110/60; Standing 90/40. There was blood in her vomit and her abdomen is hard and rigid on palpation. 2 Nursing Diagnosis 1: Central Nervous System Expected Diagnosis: The patient’s tolerance to activities will improve and this is demonstrated by: The capacity to perform daily activities effectively Resting before doing another activity Patient says the activity do not result to fatigue Nursing Diagnosis 2: Respiration system Expected Outcome: The respiratory system of the patient will resume to normal within 48 hours and this is demonstrated by: absence of cyanosis, lung’s sounds are clear and also Chest x-ray values are normal. Nursing Diagnosis 4: Digestive system Expected Outcome: The patient feeding will be normal by the time she is and this is demonstrated; No more loss in weight while during hospitalization Patient takes all the daily meals as well as three snacks everyday Nursing Diagnosis 5: Renal system Expected Outcome: By the time the patient will be discharged her excretion will be normal and this is demonstrated by; Normal levels of urine specific gravity The fluids taken and urine output corresponding Normal fluid intake The values of electrolytes and hemoglobin, being normal (Daniels, 2008). 3 The important aspects to be considered during data collections are the physiological needs. In prioritizing nursing diagnoses for Sylvia, it will be assumed that she is insulting because of alcohol usage as well as drug abuse and she is abusing alcohol and drugs due to her lack of employment leading to stress. Therefore, after placing in highest priority problems allied to Central Nervous System, heart problems demonstrated by her being tachycardic, respiratory, CvS, Digestive system, renal system in addition to musculoskeletal system, the need for a stress-free mind becomes the next priority (Schroeder, 2008). The collection of data regarding the health status of Sylvia is systematic and incessant. Therefore, the data will be handy, communicated, and recorded. Prior to the development of the nursing care plan, there will be a data base where the nursing diagnoses will be derived. The data collection will start with the initial encounter with the patient and will continue throughout her hospitalization. During the admission, an inclusive health history of Sylvia will be carried out along with physical assessment. Pertinent information will be recorded within the chart as well as within the nursing care plan. Ensuing assessments will be carried out after every nurse/patient interaction. In addition, continuing assessment will be crucial to give information in order to revise the care plan as well as meeting the ever-changing requirements of the patient (Schroeder, 2008). 4 My role will be carrying out observations on the patient and interviewing the patient to get to know about the progress of the treatment. For instance, I will interview Sylvia to get to know for how long she has been taking alcohol and abusing drugs to figure out the prolonged effects the alcohol and drugs have had on her. Through interviewing, I will establish her complete medical history which is important in her treatment and in the developing of her nursing care as well. I will also be assessing the progress and observing the progressing changes of the patient and the impact of the treatment on her. In addition, I will assess on what the patient needs. I addition, it is my responsibility to assist the patient in establishing the adaptable risk factors and also underlining to the patient the importance of adhering to the treatment routine and keeping follow up appointments (Juall, 2007). For discharge of the patient, my role is to make the appropriate arrangements with the other hospital departments in order to prepare for her discharge and ensure that the patient has received instructions from the doctor for home care and comprehends the instructions. I also have to check with nursing supervisor to ensure that there is an official discharge of the patient by the doctor and record below information: When the patient was discharged How the patient left the hospital Some of the instructions that the patient should continue adhering to after the discharge, for example medications and the dosages. Record on the chart that the patient has left with all her personal belongings (Juall, 2007). 5 As an EN, my role will be assisting in identifying nursing activities that comprise the delivery of nursing care and participants within the delivery of care as delegated by the RN. This will include evaluating and recording vital signs for the patient which will include; Examining and recording respiratory rate of the patient after every four hours and pm Examining and recording signs of hypoxia after every four hours Monitoring blood gases as recommended by the physician and reporting abnormal results to physician Instructing and helping the patient to turn and breath deeply after every two hours Monitoring the heart beat rate after every two hours and this is because of the patient’s tachycardia condition and high heart rate Monitoring the patient blood pressure and informing the physician in case of any deterioration Administration of oxygen as per instructions Informing the physician in case the breathing pattern of the patient is abnormal Assessing the patient’s postural pulses all shifts Monitoring results of the patient’s blood work Monitoring and recording precise intake and output Encouraging the patient to take fluids because of the patient’s urine output is offensive and discolored and teach her the significance of sufficient fluid intake Monitoring the food intake of the patient and making sure that the patient takes ample and nutritious food Encouraging the patient quit taking drug and alcohol and advise her on the importance of this Providing a relaxing environment for the patient Providing the patients with activities that are diversional like books, TV, and radio, as this will diminish the patient’s anxiety in her hospital stay (Myers, 2010). 6 My role as an EN in contributing to the development of individual care plans for clients is identifying the current health problems and allied functional changes and pathophysiology of the disease in the patient. As a result, I have the role of defining each primary and secondary diagnosis and explaining the disease process of all of them. This will encompass signs and symptoms, risk factors, treatment options, likely complications as well as functional changes that impact daily living undertakings. In this case, the patient’s symptoms such as vomiting blood stains, elevated blood pressure and increased heart rate and such will be noted and the likely complications (Juall, 2007). Additionally, I have a role of collecting assessment data from the patient through interviewing, observation and through physical examination as well. Therefore, the care plan of the patient will be developed immediately after the first contact with the client and after completing the assessment and reviewing the data base, the actual and potential problems will be identified and plan care accordingly. After further interactions with the patient, it is my responsibility to revise and refine the nursing care plan. The plan care will be updated regularly and it will indicate resolved problems and addition of newly-identified nursing diagnosis as this will assist in ensuring suitable, individualized care for the client (Myers, 2010). During the admission, I have the role of carrying out an inclusive health history and physical assessment. Pertinent data will be recorded within the chart and within the nursing care plan and subsequent assessment will be carried out every time there is an interaction between the patient and the nurse. I will also carry out continuing assessment to give data to update the care plan and meet the ever-changing requirements of the patient (Myers, 2010). 7 My role will be ensuring that the doctor has written a discharge order for the patient, Sylvia. I will then make the required arrangements with other departments to prepare for Sylvia’s discharge and ensure that the patient has been given instructions by the doctor for home care and that the patient adequately understands the instructions which include: Taking of the drugs Changing of dressings, for example for the IV site that has been placed in her foot Physical activities to improve her Musculoskeletal system Respiratory treatments that will be continued at home incase of recurrence of her respiratory problems (Acello et.al, 2007). Additionally, as a nurse, there is the responsibility of giving Sylvia a written copy of instructions, for instance copy of the recommended diet and an appointment card. I will also notify her family of her discharge. In addition, I will answer any questions that the patient has and ensure that all her belongings are in order and finally clean the patient’s unit. Finally, as a nurse I also have the role of charting the patient’s discharge and I will make sure that below information is charted: The date and the time of the patient’s discharge How the patient will leave the hospital Any special instructions such as, diet or drugs that Sylvia should go on taking following the discharge Finally, a notation is supposed to be made on the chart that Sylvia’s personal belongings were sent with the patient (Acello et.al, 2007). References Acello, B, et.al. (2007). Nursing Assistant: A Nursing Process Approach. California: Cengage Learning. Daniels, R. (2008). Nursing Fundamentals: Caring & Clinical Decision Making. California: Cengage Learning. Juall, C. (2007). Nursing Diagnosis: Application to Clinical Practice. New York: Lippincott Williams & Wilkins. Myers, J. (2010). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Michigan: University of Michigan. Schroeder, P. (2008). Approaches to Nursing Standards. 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