...MEDICAL MANAGEMENT: * Pain management * Fracture treatment * Realignment (aka reduction) immobilization to maintain alignment casting, splinting * Physical/occupational therapy- regaining/learning achievable mobility, ambulation and ADL capabilities * Treatment of skin integrity, complications * Maintenance/treatment of fluid volume + nutritional status MEDICAL MANAGEMENT: * Pain management * Fracture treatment * Realignment (aka reduction) immobilization to maintain alignment casting, splinting * Physical/occupational therapy- regaining/learning achievable mobility, ambulation and ADL capabilities * Treatment of skin integrity, complications * Maintenance/treatment of fluid volume + nutritional status COMPLLICATIONS * Infection * Shock – hypovolemic/hemorrhage * Pressure ulcers r/t possible decreased mobility/sensation * Compartment syndrome * Fat embolism syndrome * Muscle atrophy * Non-union (fracture doesn’t heal – no new callus formation) * Malunion (fracture heals in incorrect position, can = deformity + malfunction) * Re-fracture COMPLLICATIONS * Infection * Shock – hypovolemic/hemorrhage * Pressure ulcers r/t possible decreased mobility/sensation * Compartment syndrome * Fat embolism syndrome * Muscle atrophy * Non-union (fracture doesn’t heal – no new callus formation) * Malunion (fracture heals in incorrect position,...
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...are playing an increasingly more important role in nursing practice. With the increased utilization of nursing research comes a need for a form of communication that classifies diagnosis, applies interventions, and expected patient outcomes. In order to unify nursing communication and support nursing practice, standardized terminology has been developed. This paper will introduce three forms of standardized terminologies in nursing which are the North American Nursing Diagnosis Association (NANDA), Nursing Outcome Classification (NOC), and Nursing Intervention Classification (NIC). The purpose of this paper is to define the three standardized terminologies, processes developed, and to provide and example of their useful application in patients at risk for or diagnosed with pressure ulcers. The NANDA was established with the goal of enhancing all aspects of nursing practice by refining and promoting terminology to accurately reflect the clinical judgment of nurses (Azzolin et al., 2013). The mission of NANDA if to facilitate the refinement, dissemination, and development, and utilization of nursing standard terminology (Peres et al., 2015). Their main focus is to utilize this communication to promote evidence based practice and care, thereby improving care for everyone. NANDA promotes their missions and goals by publishing the world leading evidence based nursing diagnosis, funding research, establishing a global nursing network, and integrating evidence based terminology...
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...NURS 2410 Concept Mapping #1 Nursing Diagnosis:Impaired gas exchange Supportive Data:R/T decreased pulmonary perfusionAEB c/o SOB with any exertion, pain with deep breathing, decreased O2 saturation with ambulation. | #2 Nursing Diagnosis:Risk for bleedingSupportive Data:R/T anticoagulation therapy; Heparin drip infusing @ 13.7 mL/hr | Admitting Diagnosis/ Problem:Chest pain, back painPriority Assessments:Vital signs, telemetry, peripheral pulses, respiratory status, monitor for signs and symptoms of bleeding, pain assessment, restlessness, irritability, confusion, somnolence, tachypnea, dyspnea, significant decrease in oximetry results, decreased PaO2 and/or increased PaCO2, central cyanosis | #3 Nursing Diagnosis:Impaired physical mobility Supportive Data:R/T left lower extremity clot and right lower extremity edema and pain AEB c/o pain with ambulation and ROM of lower extremities | Relationship of Diagnoses BRIEFLY explain the relationship (causative or resultant) between your selected nursing diagnoses. If the diagnoses are unrelated, state that. The impaired gas exchange and impaired physical mobility are directly related to the patient’s diagnosis of DVT and PE. The risk for bleeding is correlated because of the heparin drip needed for the treatment of PE and DVT. | Priority Nursing Diagnosis: Goal, Outcomes, Interventions and Responses Priority Nursing Diagnosis Impaired gas exchange r/t decreased pulmonary perfusion aeb c/o SOB with any exertion...
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...Pericarditis is an inflammation of the pericardium, which is the membranous sac that encloses the heart and great vessels. The inflammatory response causes an accumulation of leukocytes, platelets, fibrin, and fluid between the parietal and the visceral layers of the pericardial sac, thus producing a variety of symptoms, depending on the amount of fluid accumulation, how quickly it accumulates, and whether the inflammation resolves after the acute phase or becomes chronic. An acute pericardial effusion is caused by an accumulation of fluid in the pericardial sac. The fluid accumulation interferes with cardiac function by compressing the cardiac chambers. Chronic constrictive pericarditis usually begins as an acute inflammatory pericarditis and progresses over time to a chronic, constrictive form because of pericardial thickening and stiffening. The thickened, scarred pericardium becomes nondistensible and decreases diastolic filling of the cardiac chambers and cardiac output. Chronic pericardial effusion is a gradual accumulation of fluid in the pericardial sac. The pericardium is slowly stretched and can accommodate more than 1 L of fluid at a time. Between 26% and 86% of people with pericarditis have illnesses that are considered idiopathic (occurring without a known cause). Pericarditis may also be classified etiologically into three broad categories: infectious pericarditis, noninfectious pericarditis, and pericarditis presumably related to hypersensitivity or autoimmunity...
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...c h a p t e r 2 Nursing Process Words to Know actual diagnosis assessment collaborative problems critical thinking data base assessment diagnosis evaluation focus assessment goal implementation long-term goals nursing diagnosis nursing orders nursing process objective data planning possible diagnosis potential diagnosis short-term goals signs standards for care subjective data symptoms syndrome diagnosis wellness diagnosis Learning Objectives On completion of this chapter, the reader will: ● ● ● ● ● ● ● ● ● ● ● ● Define nursing process. Describe six characteristics of the nursing process. List five steps in the nursing process. Identify four sources for assessment data. Differentiate between a data base assessment and a focus assessment. Distinguish between a nursing diagnosis and a collaborative problem. List three parts of a nursing diagnostic statement. Describe the rationale for setting priorities. Discuss appropriate circumstances for short-term and long-term goals. Identify four ways to document a plan of care. Describe the information that is documented in reference to the plan of care. Discuss three outcomes that result from evaluation. n the distant past, nursing practice consisted of actions based mostly on common sense and the examples set by older, more experienced nurses. The actual care of clients tended to be limited to the physician’s medical orders. Although nurses today continue to work interdependently with physicians and other health care practitioners...
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...his left side, leaving him in various states of mobility, ranging from paralysis to extremely limited. Before the accident, JB’s favorite things in life that gave him meaning and value were hunting and fishing. He comes from a large family of many brothers, so this was their familiar culture and their way establishing relationships and norms. JB just liked working with his hands and being outdoors. He mainly built houses and did construction for most of his life, but one aspect that was very proud of was that of building elaborate swimming pools and spas for a couple of the resorts in the Wisconsin Dells. He didn’t do the designing, but he took pleasure in the rebar and concrete work as well as the finishing and...
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...lead to accomplishing some goal or purpose. * A systematic and organizes method for providing care to clients. * Provides individualized, holistic, effective and efficient client care. * Clients of all ages and in any care setting. * Characteristics of Nursing Process * Problem solving method - client focused * Systematic- sequential steps * Goal oriented- outcome criteria * Dynamic-always changing, flexible * Utilizes critical thinking processes * ● Interpersonal – promotes nurse-client relationship● * Cyclical – continuous and promotes improvement of nursing care * Systematic problem - solving approach toward giving individualized nursing care. STEPS: * Assessment * Nursing Diagnosis * Planning and outcome identification * Intervention * Evaluation * ASSESSING PATIENT’S HEALTH STATUS Assessment * A systematic collection of subjective and objective data with the goal of making a clinical nursing judgment about an individual, family or community. * 1st phase of nursing process which involves systematic data collection , organization and validation, interpretation, and documentation of data. * Purpose of Nursing Assessment * To establish the client-nurse relationship. * To obtain information about the client’s health, including physiologic, socio-cultural, cognitive, developmental & spiritual aspects. * To identify actual & potential problems. * To...
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...Nightingale Executive Summary Western Governor’s University Nightingale Executive Summary Nightingale Community Hospital is a 180 bed hospital that provides acute care and a range of services to their community. Nightingale has four core values that consist of safety, community, teamwork, and accountability. Communication is a key concept in achieving and defining those values. According to the National Patient Safety Goal Data in regards to communication for Nightingale Community Hospital there is not consistency and goals are not being met for the following: reporting critical results within 60 minutes as evidenced by documentation, verbal orders/read-backs, unacceptable abbreviations, and time out hospital wide. Critical Results Within 60 Minutes Nightingale Hospital has showed variations in compliance with reporting critical results within 60 minutes for the months of January through December. Compliance went from 63% in January to 80% in December. In between this time there have been significant variances. As noted there from the data there was only 56% and 57% compliance for the months of June and July. Reporting of Critical Results with 60 minutes should be at 100% compliance. Verbal Orders/Read-Backs The ED met 100% compliance with verbal order/read-back audits for the fiscal year to date. Ortho is at 62% compliance. The other departments at Nightingale Hospital are ranging from 91% to 99%. For JCAHO standards the departments should be at 100%. ...
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...Nursing 344 Week 1: Report Writing & GFHP Report Writing Pt records are sometimes called in evidence before a court of law in order to establish events that may have contributed to a pt’s death or injury. They may also be required as evidence for an inquiry or hearing by the NMB of NSW. ▪ Frequency of documentation relies on: - physical/ mental status of the pt. - the type of care provided (self care v. intensive care) - requirements of health care agency - any legal or other obligations that the health record must meet ▪ Content of documentation needs to be: - relevant - appropriate - accurate - requirements will vary according to pt acuity - content may be guided by framework (assessment, intervention, response) ▪ Documentation framework: - assessment: conclusions reached utilising subjective and objective data - intervention: reflects the action taken - response: reflects the pt’s response to the intervention ▪ Example of using framework to case: Mrs Pat Martin, a 28y/o lady has been admitted overnight via Casualty accompanied by husband. She is 16 wks pregnant and has been diagnosed with appendicitis by Dr Chan. At the moment she is only experiencing mild pain and has a low grade fever of 37.7. IMI Pethidine 50mgs was given at 2am, and may be repeated PRN. Shes been added to the theatre list at 9.30am. She remains NMB and has IV normal saline running over 10hrs. IV Keflin QID commenced, is next due 12md...
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...Nursing Program CLIENT INFORMATION FORM Student's Name Date of Care: Client Initials Room Number Sex: Age : Admission Date: Admitting Diagnosis: Rt. Lobe infiltrate, Breast & Bone Cancer Secondary Diagnosis if any): Respiratory Distress Surgery Type/Date (if any): Lumpectomy on Rt. Foot at 2002 Working Medical Diagnosis/Etiology (describe definition, pathophysiology, and sign/symptoms) Metastatic Breast Cancer Metastatic breast cancer is the term used to describe cancer that has spread from the original site in the breast to other organs or tissues in the body. Cancer cells can break away from the original cancer in the breast and the cancer cells that break away can spread to other parts of the body via blood vessels or lymphatic vessels. The original site where the cancer cells came from is called the primary cancer. When cancer cell travels from the breast around the body they can lodge themselves in various body organs or tissues. These cells can begin to form breast cancer in new place and this new cancer is called secondary or a metastasis. Breast cancer most commonly spreads to one or more sites: bone, liver, brain and lungs. The sign or symptoms that may experience will depend on where the cancer is in the body and the extent of the cancer. If its spread to the: Bone- pain is fairly constant, aching pain. It may...
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...Comp li of F.A ments . Dav is Gordon’s functional health patterns HEALTH PERCEPTION— HEALTH MANAGEMENT PATTERN Death Syndrome, risk for Sudden Infant Energy Field Disturbance Environmental Interpretation Syndrome, impaired Falls, risk for Health Maintenance, ineffective Health-Seeking Behaviors (specify) Infection, risk for Injury (trauma), risk for Latex Allergy Latex Allergy, risk for Noncompliance (specify) Perioperative Positioning Injury, risk for Poisoning, risk for Protection, ineffective Recovery, Delayed Surgical Suffocation, risk for Suicide, risk for Therapeutic Regimen: effective management Therapeutic Regimen: ineffective management Therapeutic Regimen management: readiness for enhanced Therapeutic Regimen: Family, ineffective management Therapeutic Regimen: Community, ineffective management Trauma, risk for Wandering (specify sporadic or continual) NUTRITIONAL— METABOLIC PATTERN Aspiration, risk for Body Temperature, imbalanced, risk for Breastfeeding, effective Breastfeeding, ineffective Breastfeeding, interrupted Dentition, impaired Failure to thrive, adult Fluid Balance, readiness for enhanced Fluid Volume, risk for deficient Fluid Volume Deficient [active loss] Fluid Volume Deficit [regulatory failure] Fluid Volume Deficit, risk for Fluid Volume Excess Fluid Volume Imbalance, risk for Hyperthermia Hypothermia Infant Feeding Pattern, ineffective Latex...
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...November 17, 2012 ASSESSMENT | DIAGNOSIS | SCIENTIFIC EXPLANATION | PLANNING | IMPLEMENTATION | RATIONALE | EVALUATION | Subjective:“hindi na siya makaramdam masyado sa kanan na bahagi ng katawan niya,” as verbalized by the SOindi naObjective: * response to stimuli: * pressure (-) * tickling (-) * pain (-) * on right side of the body * patient responds to normal tone and volume of voice but does not respond to whisper on both ears * trigeminal nerve assessment (sensory) * patient was unable to feel wisp of cotton when touched on face * decreased attention span * motor incoordination | Disturbed sensory perception related to altered sensory reception, transmission or integration secondary to injury on the temporal and parietal lobe(left hemisphere) | Chronic hypertensionorArteriovenous malformations↓Rupture of diseased blood vessel↓Formation of hematoma↓Increased pressure within the brain↓Disturbance of normal brain anatomy↓Affectation of the somatosensory area in the temporal and parietal lobe of the brain↓Disturbed sensory perception | Short Term:Within the course of therapeutic regimen, the client will be able to demonstrate techniques to compensate for altered sensory perception as evidenced by: * Turning head to see people or things * Following persons or objects by moving eyes * Scanning the room for persons or objectsLong term:With continuous therapeutic regimen, the client should be able to: * Compensate for the sensory impairments * Improve...
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...corresponding “features” or characteristics” (2009). There are various ways of defining similarity the most common term shared is comparison. Accuracy and consistency are essential when providing patient care and it should be displayed within nursing practice, communication, and documentation. Institute of Medicine reports that there are over 98,000 deaths caused by preventable errors (1999). The purpose of this paper is to respond to a peer reviewed concept analysis article, describing the method of analysis, the steps of the process, results for each step and to apply the concept to a practice situation. Concept Analysis The Electronic Health Record (EHR) improves the exchange of patient data, accuracy, and quality of patient care. Poor communication and technology can impede a positive outcome for the patient. A core competence of nursing is documentation of patient’s response to nursing interventions and effectively communicating the care given. In the article Concept Analysis of Similarity Applied to Nursing Diagnoses: Implications for Educators the author uses the Walker and Avant concept analysis of similarity. In nursing, concept analysis clarifies unclear concepts and gives a mean to common understanding within nursing practice. “The purpose of a concept analysis is to describe the concept well enough so that defining characteristics can be determined and used to distinguish “likeness or unlikeness” between concepts” (Walker & Avant, 2005, p. 64). Wilson...
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...Several standard and basic techniques were used during the physical assessment of elementary students. To start, the patients were informed of the procedures in very basic terms that were understood. Height was assessed using a measuring device marked in inches. To assess accurate height, the patient must stand straight with feet close together. Weight was measured using scales marked in ounces and pounds. The BMI was determined using the data collected from height and weight. Hearing was assessed using headphones and a device that sends tones at variable decibels and hertz. If the patient wore hearing aids during screening, it was noted. Hearing was screened at 1000, 2000, and 4000 Hz beginning with 20 db. Vision was screened using two charts from a distance of 20 feet. The first chart was the Snellen letter chart and the consisted of only pictures. If the patient wore corrective lenses during screening, it was noted . Also, scoliosis was screened for by examining the patients spine while changing posture. Upon screening the results were taken and compared to find if the patient was within normal limits for the appropriate age range. Abnormal findings occur if the following apply: vision is greater than 20/30 in either eye, or a difference of two lines between both eyes; hearing is greater or equal two 30 db in either ear; the spine is curved; and weight is charted in the 85th percentile or above. Also these findings are slightly altered by gender. Deficits in any category...
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...NURSING MANAGEMENT OF A STROKE PATIENT INTRODUCTION Stroke is the only largest cause of adult disability which leaves a devastating and lasting effect on people and their families (DoH, 2007a). The government of the United Kingdom had recognized stroke as a health care priority. Several government agencies developed clinical guidelines which are being implemented today in local health care settings (Williams et al, 2010a). This essay will focus on stroke as the cause of impaired mobility and will tackle on the patient-centered rehabilitation care plan along with its evidence-based rationales. Health and social care policies and its effect on the patient’s chosen journey will also be discussed. PATIENT PROFILE This is a case of a 68 year-old, married female who lives in the south of England. Mrs. G was admitted on 12 October 2010 with a presenting complaint of left-sided weakness. Prior to admission, she experienced persistent pain on the back of the head for 2 days, which was unrelieved by Paracetamol intake. On the morning of admission, she collapsed in the bathroom and was found by the husband after 3 hours. She was brought to the hospital via ambulance and upon initial assessment, no shortness of breath, slurred speech, dizziness, palpitation and chest pain were noted. Her vital signs were as follows: blood pressure of 169/59 mmHg, pulse rate of 80 bpm, respiratory rate of 18 breaths per minute, body temperature of 37.5 degrees...
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