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NUR 214 Nursing Process Assignment Criteria Sheet Student Name:

Date of Clinical: 10/05/18 MS

Part 1: Medications and Focused Assessments 1.

Formulates possible reason(s) for each medication.

2.

Identify individualized focused assessment with rationale.

Part 2: Patient Assessment and Nursing Diagnosis 1.

Specifies subjective and objective data to assess each basic need of the patient, including a complete system assessment where indicated.

2.

Specifies patient’s understanding of health status, discharge planning and health promotion behaviors.

3.

Formulates five individualized nursing diagnoses based on the data in the assessment.

4.

Categorizes each of the five nursing diagnoses as high, medium, or low priority.

Part 3: Nursing Care Plan and Evaluation 1.

Select two of the individualized NANDA-I nursing diagnoses of high priority.

2.

Identifies defining characteristics and sufficient substantiating data for each of the two nursing diagnoses.

3.

Establishes at least two individualized patient outcomes for each nursing diagnosis.

4.

Establishes at least four individualized high priority nursing interventions to assist the patient in achieving the identified outcomes.

5.

Specifies to what degree each outcome was achieved. (yes, partially or no)

6.

Specifies patient data which shows the level of outcome achievement.

7.

Identifies adaptations made to nursing care.

8.

Determines modifications to patient care as indicated by evaluation of outcomes.

Part 4: Research/Evidence Based Article 1.

Attach 1 copy of appropriate article

2.

Annotated Bibliography with citation in APA format

Professional Behavior: 1.

Submitted on time.

2.

Written in ink.

3.

Written legibly.

DNMS

Comments

NUR 214 Nursing Process Assignment Part 1: Medications and Focused Assessments Student Name: Patient Initials: T.W. List of All Medications Patient is Taking

Date of Clinical: 10/05/18

Reason Patient is Taking

Pre/Post Administration Nursing Assessments

Acetaminophen

Pain Level less than 3

Pain assessment before and after administration

Aspirin

Aspirin Therapy; antiplatlet

Assess for pain or fever before and after administration, safety checks to prevent falls and bleeding

Atorvastatin

Lower Cholesterol

Assess fluids and electrolytes, I and Os, LFTs and cholesterol levels

Diphenoxylate Atropine

Antidiarrheal

Monitor bowel patterns and consistencies, fluid and electrolytes, abdominal distention

Enoxaparin

Blood Thinner

Monitor blood work, assess for signs and symptoms of bleeding

Fiber Powder

Bulking agent for stool

Assess stool before and after administration

Folic Acid

Supplement

Monitor blood work and nutritional status

Lacosamide

Anticonvulsant

Neurology and safety assessments before and after administration, assess for seizures

Lactobacillus Rhaminosus

Probiotic

Assess nutritional status and bowel patterns

Levetiracetam

Anticonvulsant

Neurology and safety assessments before and after administration, assess for seizures

Keppra

Anticonvulsant

Neurology and safety assessments before and after administration

Melatonin

Sleeping Aid

Assess sleeping patterns

Metronidazole

Antibiotic

Assess WBCs, vitals and wound for signs of infection before and after administration

Multivitamin

Supplement

Assess nutritional status

Omeprazole

PPI for GI

Assess electrolytes and hepatic enzymes, assess GI system (bowel sounds, pain, swelling)

Oxycontin

Pain Level greater than 3

Pain assessment before and after administration

Venlafaxine

Depression

monitor vitals, blood tests, mental

status changes

Identify components of a focused assessment for this patient with rationale. Top Three Focused Assessments (in priority order)

Rationale • • • •

Skin Assessment

Intake and Output (Fluid and Electrolytes)

Open wound near rectum Incontinence with diarrhea and urine Mostly bed bound/very little ambulation Poor nutrition

• Uncontrollable diarrhea • Poor nutrition/Annorexia • Past Medical History of seizures • Occasional Confusion • Age/Deconditioning

Neuro Assessment

Part 2: Patient Assessment and Nursing Diagnoses General Information

Patient Initials: T.W. Age:62

Gender: Female

History of present illness: IBD, Exacerbated Chrons, Peri-rectal Abcess Allergies: Cipro XR, Ciprofloxancin, Diflucan Past medical/surgical history: IBD, Toxic Megacolon, Subtotal Colectomy with Ileoanal J pouch anastomosis, colitis, chrons, Seizures, HTN, Hemorhhagic Stroke, CHF Current vital signs: T: 36.7 P: 82 BP: 130/69 RR:17 SpO2: 99% Pain Level: 5 Baseline vital signs (ranges): T: 36-37.7 P: 72-98 BP: 128/70 -145/80 R: 16-18 SpO 2: 96-100% Pain level: 3-8 Data Collection for each Basic Need Past Medical History

Subjective Data (Subjective information obtained from patient)

Objective Data (Assessment findings based on subjective information)

OXYGEN (Include normal and abnormal cardiovascular assessments)

Relevant Laboratory Values & Diagnostic Tests

Relevant Medications (all medications must be included in a basic need; may be used more than once)

PMH Carotid Stenosis CHF HTN

Subjective Data

Objective Data

Patient stated that at rest she feels no symptoms however sometimes during ambulation she feels like she “Cant catch her breath”

After ambulating across around the unit the patient appeared to be dyspneic for a few minutes, once she was settled in her bed her WOB eased. O2 sat decreased from 99% to 96% after ambulation

Elevated K+ and decreased Mg upon admissions but has since been regulated

Atorvastatin Aspirin

OXYGEN (include normal and abnormal respiratory assessments) PMH: No Past Medical History of Respiratory Issues

Subjective Data: Complains of occasional shortness of breath upon ambulation

Objective Data: Slight decrease in O2 stat after ambulating, however it increased after a few minutes of rest

REST/SLEEP/COMFORT (include normal and abnormal pain and integument assessments) PMH: Exacerbated Chrons and IBD cause GI discomfort

Subjective Data When asked to rate her pain patient rates it at a 5 caused by irritation of her peri-rectal abscess during a bowel movement and position changes

Objective Data: Patient presents with a peri-rectal abscess Patient grimaces during position changes and brief changes

Lab Values within normal limits

No Respiratory Medications presscribed

Relevant labs

Relevant meds

No relevant lab data for rest/sleep/comfort

Acetaminophen Oxycontin Venlafaxine Melatonin

ACTIVITY (include normal and abnormal musculoskeletal assessments) PMH No Past Medical History Activity Issues

Subjective Data

Objective Data

Patient states that she walks at home with her walker just fine without any help Patient stated that she feels like a child when physical therapy comes

Patient presents with some weakness, she is very reluctant to work with and lashes out at physical therapy when they assess her ambulation due to the fact she is unstable and is at risk for falls

No relevant lab data for activity

No medication related to activity

FLUIDS AND URINE ELIMINATION (include normal and abnormal elimination and IV assessments) PMH

Subjective Data

Occasional Incontinence

Patient states she cant always tell when her

Objective Data Drank with no problems including water, coffee

No monitoring of fluid intake

No medication related to fluids and urine elimiSpecific gravity, nation

brief is dry or damp

and grape juice Brief was changed twice during shift, no pain upon urination

BUN and Cr were within normal limits

Foley Catheter in place

NUTRITION (include normal and abnormal oral and nutrition assessments) PMH Chrons IBD

Subjective Data Patient declines food stating she is not hungry and that when she eats it just “runs right out” which causes her discomfort

Objective Data Patient eats 50% of meals at most Declines ensure supplements due to taste Surgeon came in and told her that she is too thin and needs to take in more nutrients Low potassium, high calorie diet

Relevant labs

Relevant meds

Intake not monitored

Omeprazole Folic Acid

Elevated K+ and decreased Mg upon admissions but has since been regulated

Multivitamin Lactobacillus Rhaminosus

BOWEL ELIMINATION (include normal and abnormal abdominal assessments) PMH IBD Chrons Colitis Subtotal colectomy with ileoanal J pouch anastamosis

Subjective Data Patient states GI discomfort and “Never ending diarrhea”

Objective Data Patients stools are yellow and loose brief changed three times throughout shift

Elevated K+ and decreased Mg upon admission due to GI losses but has since been regulated

Diphenoxylate Atropine Fiber powder

SAFETY AND SECURITY: (include normal and abnormal immunological, neurological, and environmental assessments) PMH Seizures

Subjective Data

Objective Data

Patient claims that she feels safe within the hospital

Occasional confusion to time and weakness that can be related to age and deconditioning

No relevant lab data for safety and security

Lacosamide Keppra Levetiracetam

Risk for falls

HIGHER LEVEL NEEDS LOVE/BELONGING (include assessment of patient’s interaction with support person(s))

Subjective Data

Patient stated “I wouldn’t be able to all of this without my brother, id be alone”

Objective Data Lives home alone with her cat but had a close relationship with her older brother who has supported her throughout her stay at the hospital. Her brother will be present for her surgery

RECOGNITION/ESTEEM (include educational level, occupation, etc.) Subjective Data

Objective Data

Patient states that she feels embarrassed that she cant control her stools and feels like shes on display while in the hospital

Patient is retired and graduated from highschool Low self esteem regarding her illness and her stay at the hospital

UNDERSTANDING OF HEALTH STATUS (include learning strengths, capabilities, barriers and educational needs) Subjective Data: Patient states that the colostomy will help her manage her diarrhea and hopefully will help with “the hole near her butt” (perirectal abscess)

Objective Data Patient has full understanding regarding her health status; she is able to accurately discuss her condition with little correction Knows the medications she is taking and why Understands the need for surgery

DISCHARGE PLANNING NEEDS (include assessment of ability to access available community resources) Subjective Data Believes she will need help at home with everyday activities once she is discharged

Objective Data Will need teaching pertaining to colostomy care once the surgery takes place as well as teaching in regards to the care of her perirectal abscess Will need access to supplies for colostomy care Home assistance and home PT

OTHER (include Assessment of Developmental, Socioeconomic, Emotional, Cultural, Religious and Spiritual influences on patient’s health)

Objective

Subjective Patient stated that she feel like she cant catch a break when it comes to her health, like she has no control She said that she trusts the surgeon however she is anxious that the surgery might not help

Patient was very anxious and frustrated, crying about the upcoming surgery and required alot of one on one therapeutic interventions

Nursing Diagnoses (NANDA-I) and Related Factor(s) (from Ackley)

1

Impaired Skin Integrity R/T Open Wound

2

Risk for Infection R/T Incontinence

3

Imbalanced Nutrition R/T Decreased Appetite

4

Risk for Injury R/T Deconditioning

5

Anxiety R/T Upcoming Surgical Procedure

NUR 214 Nursing Process Assignment Part 3: Nursing Care Plan Nursing Diagnosis of High Priority #1: Impaired Skin Integrity r/t Open Wound Defining Characteristics (from Ackley)

Substantiating Data

Patient Outcomes (At least 2 per diagnosis)

High Priority Nursing Interventions (At least 4 per diagnosis)

Destruction of skin layers; disruption of skin surface; invasion of body structures

Perirectal abscess a few mm deep requiring dressing changes (gauze soaked in NS placed inside abscess and covered with Allyven) during every episode of incontinence due to the location. Increased risk due to poor nutritional status decreasing wound healing Little ambulation, friction and shear and occasionally moist from BM are potential problems for increased risk of skin breakdown

Patient will describe measures to protect and heal the skin and care for any skin lesions by discharge Patient will remain dry throughout shift Patient will regain some skin integrity of skin surface by discharge

Inspect site with every bowel movement/brief change; assessing for changes in appearance or signs of infection Preform wound care with every episode of incontinence Monitor for incontinence every 2 hours to minimize exposure to moisture Position changes every two hours if patient refuses to get out of bed/ambulate or move to chair to prevent further pressure related skin break down Monitor nutritional status, encouraging an increase in caloric intake to promote wound healing

NUR 214 Nursing Process Assignment: Part 3: Evaluation

Nursing Diagnosis #1: Patient Outcomes

1. _____ Met ___x__ Partially Met _____ Unmet

2. ___x__ Met _____ Partially Met _____ Unmet

Patient Data Showing Outcome Achievement Patient was able to state methods to maintain skin intergrity when she gets home (eating more calories, making sure the site is clean and covered) Patient was monitored throughout the whole shift for incontinence and was cleaned and dried very quickly

Adaptations Made to Nursing Care

Modification after Evaluation of Outcomes (Required)

Developmental

Should Nursing Care Plan be: __x__ maintained?

Developmental age taken into consideration, allowed patient to take control and make their own decisions regarding care

____ changed? ____ discontinued? Specify Changes: Nursing Diagnoses: Same diagnosis

Socioeconomic None

Outcomes: Due to the time frame, some outcomes require more monitoring

Emotional: Provided one on one support for patient in times of distress

Describe how the patient’s participation in care facilitated/ impaired the achievement of these outcomes: Cultural None The patients skin integrity causes her great discomfort; she was very attentive to the teaching regarding to her skin care and was able to identify when her brief was soiled with feces which increased the efficiency in changing her brief and maintaining dry skin integrity

Nursing Interventions: Collaborating with nutritional therapy

Religious None Spiritual None

Rationale: I believe that requesting a consult with nutritional therapy would help her maintain her nutritional status

Nursing Diagnosis of High Priority #2: Risk for Infection r/t Incontinence Defining Characteristics

Chronic disease, inadequate primary defenses (broken skin), traumatized tissue, stasis of body fluids, malnutrition

Substantiating Data

Patient has an open wound next to the rectum; She is incontinent therefore, every time she has a bowel movement (uncontrolled diarrhea), it enters the open wound which requires dressing changes at every bowel movement. This increases the risk for infection greatly

Patient Outcomes (At least 2 per diagnosis)

Patient will remain free of infection throughout hospital stay Patient will demonstrate appropriate care of site by the end of the shift Patient will maintain adequate nutrition by discharge patient will remain unconditioned

High Priority Nursing Interventions (At least 4 per diagnosis)

Observe and report signs of infection (redness, warmth, increased temp) Use hand hygiene when preforming all care Encourage fluid intake and nutritional maintenance Assess skin integrity, color, turgor, texture Monitor for incontinence every 2 hours

Nursing Diagnosis #2: Patient Outcomes

1. _____ Met ____x_ Partially Met _____ Unmet

2. _____ Met _____ Partially Met __x___ Unmet

Patient Data Showing Outcome Achievement Patient remained free of infection throughout the shift: no redness, swelling or increased temperature

Adaptations Made to Nursing Care

Modification after Evaluation of Outcomes (Required)

Should Nursing Care Plan be: __x__ maintained? Developmental age taken ____ changed? into consideration, allowed ____ discontinued? patient to take control and make their own decisions Specify Changes: regarding care Developmental

Patient was not able to preform her own wound care due to weakness and Socioeconomic lack of visibility of the area.

Nursing Diagnoses

I would keep the nursing diagnosis the same

None

Emotional Provided one on one support for patient in times of distress and anxiety

Outcomes: Due to the time frame, some outcomes require more monitoring, I would change the second outcome to “Patient will maintain a WBC blood count within normal limits throughout hospital stay”

Describe how the patient’s participation in care facilitated/ impaired the achievement of these outcomes: Cultural Patient is compliant and willing to do everything she can to feel better and “not end up back in a hospital” this helps facilitate nursing care

None

Nursing Interventions: I would add “Monitor CBC values”

Religious None Spiritual None

Rationale: An increase in WBCs can indicate a possible infection

I chose this article because it went more in depth about how having Crohns can deteriorate your skin over time, discussing the different types of skin conditions associated with Crohns as well as how to protect and prevent further skin damange. While it is a GI disorder, the second most common problem associat...