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WEEK 2 NURS 211L - Nursing Process Worksheet
Nutrition (N225)
West Coast University
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Course: NURS 211L NURSING PROCESS WORKSHEET
Date: November 10, Student Name: Caroline Howe
Faculty Name: Professor Chrisine Corcoran
Instrucions: Each clinical day each student will develop a nursing process outline for one paient of their choice. These are quick writes and should be done throughout the shit and not taken home. These will be discussed in post conferences with the faculty. The outline will be as follows: Arthur Thomason 56 year old MVA vicim, fourth day post op with a splenectomy.
Assessment (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Obj: Neuro: paient gets confused but can be reoriented to place. He is A/Ox 3. His vital signs are RR:30 bpm, HR 100 bpm, BP:146/94, Temp: 102 temporal, O2 Sat: 98% with 2L nasal cannula. Resp: coughing, inefecive in
clearing secreions. Bilaterally heard crackles in the lungs. His breathing is labored, and chest x-ray showed
bilateral intersiial iniltrates in all lobes. Falling PaO2 and rising CO2. His skin is cool and dry.
Subj: Mr. Thomason reports feeling anxious and sob. He says he feels generally worse all over since yesterday.
Nursing Diagnosis (2) Must be prioriized. Must be Nanda using three part statement (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Stem (DX): Eiology (Cause): as evidenced by (Signs and symptoms) Abnormal Assessment Findings. (1) Impaired gas exchange related to bilateral intersiial iniltrates in all lobes as evidence by crackled
auscultated in all lobes, and falling PaO2 and rising CO2 levels.
(2) Inefecive airway clearance related to increased sputum producion as evidence by nonproducive cough.
Planning (Paient goals) Must be SMART goals Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain) by the: (end of shit, end of day, discharge day) or within: (two hours; 12 hours, etc.) Paient will paricipate in acions to maximize oxygenaion by the end of teaching.
Paient will display efecive airway clearance ater RT and I teach him how to mobilize secreions. Implementaion (Speciic nursing intervenions that were performed during your shit): Must contain the following: Assess {observe, palpate, percuss}; Monitor; Administer; Collaborate w/ speciic muli-disciplinary team; & Teach We will raise the head of Arthurs bed and keep the O2 cannula on him. We will itrate as needed. We will demonstrate to Arthur how to take deep breaths to maximize oxygenaion, and have him teach back to us. We
will call for an RT consult, to help mobilize secreions, and show Arthur how to efecively clear his airway. We
will maintain adequate hydraion so those secreions can move easier and be cleared more readily.
Evaluaion (What was the outcome: Goal; Met or Not met or Parially met and How to revise.) Both goals were met. Arthur was able to demonstrate how to maximize his oxygenaion through changing posiions, keeping his head and thorax elevated, and his breath patern. We were able to also clear some secreions with the help of RT, and clear his airway a bit beter. He verbalized feeling much beter ater doing so. Nursing Applicaion Assessment Include aciviies throughout the day performed in relaion to the following NCLEX content categories. See content category examples below as cited by NCSBN
Management of Care We made sure to keep a close eye on Arthur Thomason, and assist him in his respiratory problems. We got him an incenive spirometer, so he can really expand and stretch his lungs, for opimal oxygenaion. We also
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Course: NURS 211L NURSING PROCESS WORKSHEET
worked alongside a respiratory therapist, who was able to teach Arthur more about how to mobilize secreions, and get more oxygen. Safety and Infecion Control We made sure to perform hand hygiene, and don the proper PPE when going into Arthurs room. When Arthur was confused we were able to reorient him to place, and he was easily reminded. He is a fall risk, so we insured fall risk precauions in his room. Basic Care and Comfort We ensured Arthur was comfortable by administering an analgesic, and also applying oxygen nasal cannula to aide his respiraions. He reported feeling much more comfortable ater the intervenions.
Management of Care: providing and direcing nursing care that enhances the care delivery seting to protect clients and health care personnel.
Related content includes but is not limited to: Advance Direcives. Advocacy, Assignment, Delegaion and Supervision, Case Management, Client Rights, Collaboraion with Interdisciplinary Team, Concepts of Management, Conideniality/Informaion Security, Coninuity of Care, Establishing Prioriies, Ethical Pracice, Informed Consent, Informaion Technology, Legal Rights and Responsibiliies, Performance Improvement (Quality Improvement), Referrals
Safety and Infecion Control : protecing clients and health care personnel from health and environmental hazards.
Related content includes but is not limited to: Accident/Error /Injury Prevenion, Emergency Response Plan, Ergonomic Principles, Handling Hazardous and Infecious Materials, Home Safety Reporing of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard Precauions/Transmission- Based Precauions/Surgical Asepsis, Use of Restraints/Safety Devices
Basic Care and Comfort : providing comfort and assistance in the performance of aciviies of daily living.
Related content includes but is not limited to: Assisive devices, Eliminaion, Mobility/Immobility, Non- Pharmacological Comfort Intervenions, Nutriion and Oral Hydraion, Personal Hygiene, Rest and Sleep
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WEEK 2 NURS 211L - Nursing Process Worksheet
Course: Nutrition (N225)
University: West Coast University
