Use this case study to create one, complete nursing diagnosis. The nursing diagnosis should be one of the top three nursing diagnoses for this patient. A priority nursing diagonsis is one that applicable to the major presenting problem(s).
An 80-year-old White male was admitted s/p L hemiarthroplasty yesterday after a fall. No other acute injuries were treated. Patient is married and his wife and daughter are at the bedside. Patient has a history of type 2 diabetes but does not require medication normally, though he is currently on a sliding scale of insulin since surgery. He had an Ivor-Lewis esophagectomy secondary to adenocarcinoma of the esophagus and stomach 9 months ago. He also had gamma knife radiation for a left temporal mass (7 months ago) which was found coincidentally when diagnosed with a CVA.
He has a port-a-cath in his right upper chest which is not accessed. He has a left-hand peripheral IV of normal saline at 100 cc/hour and the pump that is alarming (which is what brought you into the room). His IV site is swollen and red.
He is alert and oriented Xs 3. HOB must be at 30 degrees at all times. Patient is 6 feet 6 inches tall and weighs 168 pounds. Skin is extremely fragile and tears easily. He currently has a reddened area over his coccyx, though skin is intact. Patient must not drink fluids within 30 minutes of meals, must eat a small, high-protein meal every 2 to 3 hours, and must rest at least 20 minutes after eating; otherwise he experiences dumping syndrome.
Vitals: BP 150/68 (supine); P 70; R 24; O2 at 97% on room air. Breath sounds diminished in lower lobes bilaterally. Bowel sounds are decreased in all quadrants. Left hip dressing is dry and intact. Client states his pain is a 6 out of 10; he was last medicated 4 hours ago and has asked to have pain medicine and nausea medicine at the next opportunity. Pedal pulses are present bilaterally, no swelling. Blood work indicates Hgb of 8.1.
When physical therapy (PT) attended earlier, patient stood at bedside with walker and assistance, but quickly became nauseous and weak and was unable to transfer to the chair. Client lives with wife of 60 years. There are two steps into the residence, and patient was independent with all ADLs prior to the fall. He is currently resting; a soft meal was brought in, but patient has refused to eat or drink since he fell 2 days ago.
The following list contains common NANDA approved nursing diagnosis examples. You can use these to help get ideas on how to develop your nursing care plan. If you have access to current care plan books, you are welcome to refer to these as well for nursing diagnoses and interventions. Whatever you decide to use, be sure to include a reference for it.
Additional examples of care plans can be found here: https://nurseslabs.com/category/nursing-care-plans/nursing-diagnosis/
The concept map can be any shape or color, but must include the criteria listed in the rubric and be reasonable to read. In the past, students have chosen to use powerpoint, draw on a paper and upload, or for the tech savvy used various apps to design their concept map of the careplan they have chosen. Check the course schedule to see due dates for assignments.
Make sure to use the following criteria,
Describe the primary concern that caused the patient to seek healthcare.
–Past medical history
Include as much as you are able to determine
-Priority Nursing Dx
The nursing diagnosis cannot be a medical diagnosis. It must also be the address the most concerning patient problem (what is most dangerous to the person's health at the moment and needs to be resolved as soon as possible).
Contributing factors influencing the change in health status. No medical diagnoses can be used unless they are addressed as secondary. (see example below).
Risk for Decreased Cardiac Output related to reduced preload secondary to myocardial infarction as evidence by patient reporting angina, decreased venous and arterial oxygen saturation, hypotension (80/56).
Give two examples of objective data that supports your nursing diagnosis. Give one example of subjective data that supports your nursing diagnosis.
-Short term goal
Include a short term goal related to your patient AND priority nursing dx that is S.M.A.R.T. SMART goals are Specific, Measurable, Achievable, Relevant, and Time-Bound
-Long Term Goal
Include a long term goal related to your patient AND priority nursing dx that is S.M.A.R.T.
Include 8 interventions you can use to meet the short term and long term goals.
One must be a medication and one must be something non-pharmacological. Only one intervention can be an assessment or continue to assess.
-Evaluation- follow up physical assessment
Normally in the evaluation phase, you would include any new assessment findings for each intervention that was chosen. In this case, you can create your own findings to demonstrate what you would expect to find after the interventions have been implemented.
-Evaluation of goals- short term
Determine if the short term goal was met, partially met, or not met. Indicate why you have chosen your answer.
-Evaluation of goals: long term goal
Determine if the long term goal was met, partially met, or not met. Indicate why you have chosen your answer.
Must include reference in APA 7th edition format.