Pts Needs
Call the physician immediately to clean/suture the wound site.
BMI is low. Re-educate the importance of nutritional intake.
Ask for a X-ray of the abdomen
Ask pt to point to where the pain is occurring
Pts Nursing Diagnosis
Impaired skin integrity-Kevin and LaShare
Chronic Pain-Ruth and Roxy
Fluid Volume Deficit-Chris and Aja
Risk for Infection-Maria and Jenny B
Risk for Falls- Lizzie and Katie
Nutrition Imbalance; less than body requirements-Cory and Dustin
Body Image-Chad and David
Coping, Ineffective-Allison and Pearl
Nausea-Maria B
Risk for Constipation-Marcos
Self-Care Deficit-Rafael
Low-self Esteem- Allison and Pearl
Ineffective-role performance-Roxy and Ruth
Family processes interrupted- Chris and Aja
Risk for unstable glucose- Lizzie and Katie
Risk for tissue perfusion- Maria and Jenny B
Pts Medical Diagnosis
Anorexia
Bulimia
Hysterectomy
Bowel Obstruction
UTI
Depression
Diabetes
Chris is going to do the drug look-up
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Presented by: Kevin Cody & LaShare Edwards
Identify Nursing Problem:
Complete Wound Dehiscence
Identify the Primary NANDA nursing diagnosis for your patient:
Impaired Skin Integrity, Altered epidermis and /or dermis
Defining Characteristics: Destruction of skin layers, disruption of skin surface, invasion of body structures
Three interventions for the diagnosis (NIC)
1. Assess site of skin impairment and determine cause ie. Acute or chronic wound, pressure ulcer or skin tear
Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain or other signs of infection
2. Determine cleansing agents to be used, avoid extreme friction or force or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Wound, Ostomy, and Continence Nurses Society [WOCN] 2003).
3. Wound care, select appropriate dressing for wound maintain clean environment in the affected area
Identify how you would evaluate your outcome for each intervention (NOC):
1. Client will to regain integrity of skin surface within specify time frame
2. Report any altered sensation or pain at the site of skin impairment
3. Describe measures to protect and heal the skin and to care for any skin lesion
Ackley, Betty . J, Ladwig, Gail. B (2008) . Nursing Diagnosis Handbook. An evidence-Based to Planning Care. 8th Edition Retrieved 27 November 2008 from http://www.evolvels.elsevier.com
Baranoski, Sharon : Wound care essentials: practice principles, Springhouse, Penn (2003), Lippincott, Williams & Wilkins.
Presented by: Katie Osborne and Elizabeth Briggs
Identify Nursing Problem:
Increased susceptibility to falling that may cause physical harm.
Nursing Diagnosis:
Risk for Falls
Defining Characteristics:
Narcotic use, postoperative conditions, diabetic
Three interventions for the diagnosis (NIC):
1. Evaluate the client’s medication ot determine whether they increase the risk of falling.
Polypharmacy has been associated with increased falls.
2. Thoroughly orient the client to the environment. Place the call light within reach and show how to cal for assistance; answer call light promptly.
3. Routinely assist the client with toileting on his or her own schedule. Always take the client to the bathroom on awakening, before bedtime and before administering sedatives.
Evaluate your outcome for each intervention (NOC):
1. Pt will remain free of falls within specified time frame
2. Change the environment to minimize the incidence of falls
3. Explain methods to prevent injury
Ackley, Betty . J, Ladwig, Gail. B (2008) . Nursing Diagnosis Handbook. An evidence-Based to Planning Care. 8th Edition
Presented by: Maria Ballesteros
Identify Nursing Problem:
Increased susceptibility to falling that may cause physical harm.
Nursing Diagnosis:
Nausea
Defining Characteristics:
Aversion to food; gagging sensation; increased salivation; increased swallowing; report of nausea; sour taste in mouth
Interventions for the diagnosis (NIC):
• Determine cause of N&V (e.g., medication effects, viral illness, food poisoning, extreme anxiety, anesthetic agents, pregnancy). Since most episodes of N&V are now preventable, it is important for the cause to be determined (Garrett et al, 2003).
• If nausea is associated with frequent vomiting, assess client for fluid and electrolyte imbalances. Protracted vomiting can cause hyponatremia, hypokalemia, or dehydration (Garrett et al, 2003).
• Medicate the client for nausea as ordered. EB: Antiemetic medications can reduce the incidence of postoperative nausea and vomiting (PONV), and use of more than one medication may be needed (Apfel et al, 2004).
• Ensure that the nauseated client is not hypotensive. Check blood pressure and note signs of postural hypotension. Postural hypotension can be caused by deficient fluid volume following surgery and can result in nausea (Garrett et al, 2003).
• Use relaxation, imagery, and distraction techniques for nausea; encourage the client to take slow, deep breaths. Deep breaths can serve as a distraction technique and can help rid the body of the anesthetic agent.
Evaluate your outcome for each intervention (NOC):
Client Will:
• State relief of nausea
• Explain methods they can use to decrease nausea and vomiting (N&V)
• Regain normal levels of
o Hydration
o Nutritional Status: Food and Fluid Intake
o Nutrient Intake
Reference:
Ackley, Betty . J, Ladwig, Gail. B (2008) . Nursing Diagnosis Handbook. An evidence-Based to Planning Care. 8th Edition
Identify Nursing Problem:
Risk for variation of blood glucose/sugar levels from the normal range
Nursing Diagnosis:
Risk for unstable blood Glucose
Three interventions for the diagnosis (NIC):
1. Observer for signs and symptoms of hypoglycemia, changes in level of consciousness, coll/clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness
2. Monitor for signs and symptoms of hyperglycemia, such as polydipsia, polyuria, and polyphagia.
3. Administer intravenous 50% dectrose or intramuscular glucagon according to agency protocol if client is hypoglycemic and is unable to talk oral carbohydrate.
Evaluate your outcome for each intervention (NOC):
1. Maintain blood glucose level between 90 and 130 mg/dL
2. Demonstrate usual energy level
3. Ingest appropriate amounts of calories/ nutrients
NANDA nursing diagnosis for patient:
Ineffective Coping
Defining Characteristics:
fatigue, inability to meet role expectation, inability to meet basic needs,
Interventions:
-observe for contributing factors of ineffective coping such as poor self-concept, grief, lack of problem solving skills, recent change in life situation
-use of verbal and nonverbal therapeutic communication approaches including *empathy, active listening, confrontation to encourage client and family to express emotions such as sadness, guilt, and anger, verbalize fears and concerns
-collaborate with client to identify strengths such as ability to relate the facts and to recognize the source of stressors
-discuss the client’s and family’s power to change a situation or the need to accept a situation
-encourage use of social support resources
-assist client to set realistic goals and identify personal skills and knowledge
Patient outcome
-Use effective coping strategies
-Use of behaviors to decrease stress
-Remain free of destructive behavior toward self or others
-Report decrease in physical symptoms of stress
-report increase in psychological comfort
-seek help from healthcare professional as appropriate
client/family teaching
-teaching the client to problem solve. Have client define the problem and cause, and list the advantages and disadvantages of the opinion
-provide seriously ill client and his or her family with needed information regarding the condition and treatment
-work closely with client to develop appropriate educational tools that address individualized needs
-teach client about the available community resources
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