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Process Paper 1
Running Head: Nursing Process Paper
Isis Cruz
Nursing Process Paper
Westminster College
Process Paper 2
I. General information
Age 81
Sex Female
Dates of care 10/16/2013
Admitting diagnosis and date Degenerative Joint Disease 10/15/2013
Surgery (if applicable) and date Arthroplasty of the left knee. 10/15/2013
II. Assessment
Health Perception – Health Management
1. Chief complaint (Why did the patient come to the hospital?)
The patient has been suffering from left knee pain for the past several years and it
was decided by her primary care provider that she have a left total knee
arthroplasty.
2. Review general health (past medical history; other health problems)
1. Health problems Patient suffers from COPD, Hypertension, Chronic
Heart Failure, and Dementia. Past surgery and hospitalization history
includes: Appendicitis, Hysterectomy, Complete Vein Ligation (Both
Legs), Left Knee ACL Surgery, Cholecystectomy, Mitral Valve
Replacement Single Bypass, Right Hip Surgery, and Transient
Ischemic Attack.
2. Allergies Demerol (Meperidine). Allergic reaction: nausea and
vomiting
3. Medications (for each medication the patient is getting)
Medication: Metoprolol Succinate
Dose: 100 mg
Safe dose? Yes
Frequency: Once daily
Reason for getting: Treatment for hypertension and management of heart
failure.
Side Effects/nursing implications:
CNS: fatigue, weakness, anxiety, depression, dizziness, drowsiness,
insomnia, memory loss, mental status changes, nervousness, nightmares.
EENT: blurred vision, stuffy nose.
Resp: bronchospasm, wheezing.
CV: BRADYCARDIA, HF, PULMONARY EDEMA, hypotension,
peripheral vasoconstriction.
GI: constipation, diarrhea, drug-induced hepatitis, dry mouth, flatulence,
gastric pain, heartburn, liver enzymes, nausea, vomiting.
GU: erectile dysfunction, libido, urinary frequency.
Derm: rashes.
Endo: hyperglycemia, hypoglycemia.
MS: arthralgia, back pain, joint pain.
Misc: drug-induced lupus syndrome.
Medication: Lisinopril
Dose: 10 mg
Safe dose? Yes
Frequency: Once daily
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Reason for getting: Management of hypertension and heart failure
Side Effects/nursing implications:
CNS: dizziness, fatigue, headache, weakness.
Resp: cough.
CV: hypotension, chest pain.
GI: abdominal pain, diarrhea, nausea, vomiting.
GU: erectile dysfunction, impaired renal function.
Derm: rashes.
F and E: hyperkalemia.
Misc: ANGIOEDEMA.
Medication: Simvastatin Zocov
Dose: 20 mg
Safe dose? Yes
Frequency: Once at night
Reason for getting: Secondary prevention of MI
Side Effects/nursing implications:
CNS: dizziness, headache, insomnia, weakness.
GI: abdominal cramps, constipation, diarrhea, flatus, heartburn, altered
taste, drug-induced hepatitis, dyspepsia, liver enzymes, nausea,
pancreatitis.
GU: erectile dysfunction.
Derm: rashes, pruritus.
MS: RHABDOMYOLYSIS, arthralgia, myalgia, and myopathy (risk with
80 mg dose).
Misc: hypersensitivity reactions.
Medication: Alprazolam Xanax
Dose: 0.5 mg
Safe dose? Yes
Frequency: Once at night
Reason for getting: Management of panic and anxiety disorder
Side Effects/nursing implications:
CNS: dizziness, drowsiness, lethargy, confusion, hangover, headache,
mental depression, paradoxical excitation.
EENT: blurred vision.
GI: constipation, diarrhea, nausea, vomiting, weight gain.
Derm: rash.
Misc: physical dependence, psychological dependence, tolerance.
Medication: Oxybutynin
Dose: 5 mg
Safe dose? Yes
Frequency: Two times a day (am & pm)
Reason for getting: Management of urge incontinence and nocturia
Side Effects/nursing implications:
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CNS: dizziness, drowsiness, agitation, confusion, hallucinations,
headache.
EENT: blurred vision.
CV: tachycardia.
GI: constipation, dry mouth, nausea, abdominal pain, diarrhea.
GU: urinary retention.
Derm: sweating, transdermal only: application site reactions, pruritus.
Metab: hyperthermia.
Misc: ANAPHYLAXIS, ANGIOEDEMA.
Medication: Ipratropium Bromide
Dose: 0.03%
Safe dose? Yes
Frequency: 2 sprays in each nostril two times a day
Reason for getting: Treatment for COPD
Side Effects/nursing implications:
CNS: dizziness, headache, nervousness.
EENT: blurred vision, sore throat, nasal only, epistaxis, nasal
dryness/irritation.
Resp: bronchospasm, cough.
CV: hypotension, palpitations.
GI: GI irritation, nausea.
Derm: rash.
Misc: allergic reactions.
Medication: Fluticasone Propionate
Dose: 50 mcg
Safe dose? Yes
Frequency: 1 spray in each nostril once a day
Reason for getting: prophylactic treatment for asthma
Side Effects/nursing implications:
CNS: headache, dizziness.
EENT: dysphonia, hoarseness, oropharyngeal fungal infections, nasal
stuffiness, rhinorrhea, sinusitis.
Resp: bronchospasm, cough, upper respiratory tract infection, wheezing.
GI: diarrhea.
Endo: adrenal suppression (high-dose, long-term therapy only)
mineral density, growth (in children), Cushing's syndrome.
MS: muscle pain.
Misc: HYPERSENSITIVITY REACTIONS INCLUDING
ANAPHYLAXIS, LARYNGEAL EDEMA, URTICARIA, AND
BRONCHOSPASM CHURG-STRAUSS SYNDROME, fever.
Medication: Guaifenesin
Dose: 400 mg
Safe dose? Yes
bone
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Frequency: 3 times daily
Reason for getting: Treatment of upper respiratory tract infections
Side Effects/nursing implications:
CNS: dizziness, headache.
GI: nausea, diarrhea, stomach pain, vomiting.
Derm: rash, urticaria.
Medication: Warfarin
Dose: 57.5 mg
Safe dose? Yes
Frequency: Daily
Reason for getting: Prophylaxis and treatment of: Venous thrombosis,
Pulmonary embolism, Atrial fibrillation with embolization. Management
of myocardial infarction
Side Effects/nursing implications:
GI: cramps, nausea.
Derm: dermal necrosis.
Hemat: BLEEDING.
Misc: fever.
Medication: Acetylsalicylic Acid
Dose: 81 mg
Safe dose? Yes
Frequency: Once daily
Reason for getting: Prevention of MI
Side Effects/nursing implications:
GI: heartburn
Hemat: bleeding
Medication: Coenzyme Q-10
Dose: 30 mg
Safe dose? Yes
Frequency: once daily
Reason for getting: Heart failure
Side Effects/nursing implications:
CNS: dizziness.
CV: hypotension.
Derm: rash.
GI: nausea, vomiting, diarrhea, heartburn, decreased appetite.
Medication: Cetirizine
Dose: 10 mg
Safe dose? Yes
Frequency: once daily
Reason for getting: Treatment of allergic rhinitis
Side Effects/nursing implications:
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CNS: dizziness, drowsiness (significant with doses >10 mg/day), fatigue.
EENT: pharyngitis.
GI: dry mouth.
Medication: Nitroglycerin
Dose: 0.4 mg
Safe dose? Yes
Frequency: PRN
Reason for getting: Treatment of angina and management of HF
Side Effects/nursing implications:
CNS: dizziness, headache, apprehension, restlessness, weakness.
EENT: blurred vision.
CV: hypotension, tachycardia, syncope.
GI: abdominal pain, nausea, vomiting.
Derm: contact dermatitis (transdermal).
Misc: alcohol intoxication (large IV doses only), cross-tolerance, flushing,
tolerance.
Medication: Fentanyl Sublimaze
Dose: 12.5 mcg
Safe dose? Yes
Frequency: PRN
Reason for getting: Therapy for pain secondary to surgery.
Side Effects/nursing implications:
CNS: confusion, paradoxical excitation delirium, postoperative drowsiness
EENT: blurred/double vision
RESP: Apnea, laryngospasm respiratory depression
CV: arrhythmias, bradycardia, circulatory depression
Medication: Hydralazine
Dose: 5 mg
Safe dose? Yes
Frequency: PRN
Reason for getting: management of HF
Side Effects/nursing implications:
CNS: dizziness, drowsiness, headache
CV: tachycardia, angina, arrhythmias, edema, orthostatic hypotension
GI: diarrhea, nausea, vomiting
Derm: rash
F and E: sodium retention
MS: arthritis
Neuro: peripheral neuropathy
Medication: Hydromorphone Dilaudid
Dose: 0.2 mg/10/ clinician bolus
Safe dose? Yes
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Frequency: PRN
Reason for getting: Decrease severe pain
Side Effects/nursing implications:
CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling,
hallucinations, headache.
CV: hypotension, bradycardia
Resp: respiratory depression
GI: constipation, dry mouth, nausea, vomiting
GU: urinary retention
Derm: flushing, sweating
Medication: Morphine Sulfate Astramorph
Dose: 2-4 mg
Safe dose? Yes
Frequency: PRN
Reason for getting: Decrease severe pain
Side Effects/nursing implications:
CNS: confusion, sedation, dizziness, dysphoria, euphoria, hallucinations,
headache
EENT: blurred vision, diplopia, miosis
Resp: respiratory depression
CV: hypotension, bradycardia
GI: constipation, nausea, vomiting
GU: urinary retention
Derm: flushing, itching, sweating
Medication: Ondansetron
Dose: 4 mg
Safe dose? Yes
Frequency: PRN
Reason for getting: to decrease incidence and severity of nausea and
vomiting following surgery.
Side Effects/nursing implications:
CNS: headache, dizziness, drowsiness, fatigue, weakness
CV: torsade de pointes, QT interval prolongation
GI: constipation, diarrhea, abdominal pain, dry mouth
Neuro: extra pyramidal reactions
Medication: Donezepil
Dose: 5 mg
Safe dose? Yes
Frequency: Once daily
Reason for getting: Management of Alzheimer’s disease
Side Effects/nursing implications:
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CNS: headache, abnormal dreams, depression, dizziness, drowsiness,
fatigue, insomnia, syncope, sedation (unusual).
CV: atrial fibrillation, hypertension, hypotension, vasodilatation.
GI: diarrhea, nausea, anorexia, vomiting, weight gain (unusual).
GU: frequent urination.
Derm: ecchymoses.
Metab: hot flashes, weight loss.
MS: arthritis, muscle cramps.
4. Pathophysiology for all conditions that the patient is being treated for (getting
medication for and/or getting other treatment for) – Describe usual treatment and
complications. Indicate which signs, symptoms, treatments, and complications your
patient is experiencing
Degenerative Joint Disease (DJD)
Degenerative joint disease is a degeneration or “wear and tear” of articular cartilage
usually accompanied by an overgrowth of bone, narrowing of the joint space, sclerosis or
hardening of bone at the joint surface, and deformity in joints.
Because there is no cure, the treatment of DJD is symptomatic and includes physical
rehabilitative, pharmacologic, and surgical measures. Physical measures are aimed at
improving the supporting structures of the joint and strengthening opposing muscle
groups involved in cushioning weight-bearing forces. This includes a balance of rest and
exercise, use of splints to protect and rest the joint, use of heat and cold to relieve pain
and muscle spasm, and adjusting the activities of daily living. Weight reduction is helpful
when the knee is involved. Muscle-strengthening exercises may help protect the joint and
decrease pain. Oral medications are aimed at reducing inflammation or providing
analgesia. Popular medications used in the treatment of DJD are the NSAIDs. Intraarticular corticosteroid injections may be used when other treatment measures have been
unsuccessful in adequately relieving symptoms. Surgery is considered when the person is
having severe pain and joint function is severely reduced. Procedures include
arthroscopic lavage and debridement, bunion resections, osteotomies to change alignment
of the knee and hip joints, and decompression of the spinal roots in osteoarthritic
vertebral stenosis.
Typically the major symptom of DJD is joint pain. Pain may be described as aching and
difficult to localize. It usually worsens with use or activity and is relieved by rest. Night
pain may be experienced during rest. Cracking of joints or audible crepitus and joint
locking may occur when the joint is moved. As the disease advances, even minimal
activity may cause pain.
Clinical features the patient presented with included localized discomfort with severe
pain on motion, limitation of motion, and crepitus. Treatment consisted of total knee
replacement to provide effective relief of symptoms and improve range of motion.
Lack of use, and joint instability. Patient is currently on supplemental calcium as well as
multiple opiod treatment for severe pain.
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Chronic Heart Failure (CHF)
The term heart failure denotes the failure of the heart to pump enough blood to meet the
metabolic needs of the body. HF has been defined as a complex syndrome resulting from
any functional or structural disorders of the heart that results in or increases the risk of
developing manifestations of low cardiac output and or pulmonary or systemic
congestion. The syndrome of heart failure can be produced by any heart condition that
reduces the pumping ability of the heart. Among the most common causes of HF are
coronary artery disease, hypertension, dilated cardiomyopathy, and valvular heart
disease.
The manifestations of HF depends on the extend and type of cardiac dysfunction that is
present and the rapidity with which it develops. The manifestations of HF reflect the
physiologic effects of the impaired pumping ability of the heart, decreased renal blood
flow, and activation of sympathetic compensatory mechanisms. The signs and symptoms
include fluid retention and edema, shortness of breath and other respiratory
manifestations, fatigue, weakness and mental confusion; limited exercise tolerance,
cachxia, malnutrition, and cyanosis; arrhythmias and sudden cardiac death.
The goals of treatment for HF are determined by the rapidity of onset and severity of the
HF. Persons with acute HF requires urgent therapy directed at stabilizing and correcting
the cause of the cardiac dysfunction. For persons with chronic HF, the goals of treatment
are directed toward relieving the symptoms, improving the quality of life, and reducing or
eliminating risk factors with the long term goal of slowing, halting or reversing the
cardiac dysfunction. Treatment measures include pharmacologic and nonpharmacologic
approaches. Mechanical support devices and ventricular assist devises.
RK’s present symptoms include fatigue, weakness, mental confusion and limited exercise
tolerance. RK’s treatment consists of pharmacologic therapy including a diuretic,
angiotensins and ACE inhibitors.
Hypertension
A condition in which the blood pressure is higher than 140 mm Hg systolic or 90 mm Hg
diastolic on three separate readings recorded several weeks apart. Hypertension results
from many different conditions, some curable and others treatable. Curable forms of
hypertension may be caused by coarctation of the aorta, pheochromocytoma, renal artery
stenosis, primary aldosteronism, and Cushing’s syndrome. Excess alcohol consumption is
a common cause of high BP; Aortic valve stenosis, pregnancy, obesity and the use of
certain drugs also may lead to hypertension. Usually, however the cause is unknown.
Hypertension is usually a “silent” or asymptomatic disease in the first few decades of its
course. Occasionally, patients with hypertension report headache. When complications
result from high BPs, patients mention symptoms referable to the affected organs.
Treatment includes lifestyle changes including increasing level of exercise, decreasing
the amount of calories and fat in the diet, and achieving sensible weight loss. An
antihypertensive medication is based on the stage of hypertension and it includes
diuretics, ACE inhibitors, calcium channel blockers and vasodilators.
The patient was diagnosed with hypertension at age 50 with no symptoms present. She
has since then been on pharmacological therapy for management of her hypertension. She
takes a Beta blocker (Metroprolol) as well as an ACE inhibitor (Lisinopril). Patient also
made lifestyle changes such as increasing her exercise levels and improving her diet.
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Chronic Obstructive Pulmonary Disease (COPD)
COPD denotes a group of respiratory disorders characterized by chronic and recurrent
obstruction of airflow in the pulmonary airways. The airflow obstruction is usually
progressive, may be accompanied by airway hyper reactivity, and may be partially
reversible. The mechanisms involved in the pathogenesis of COPD usually are multiple
and include inflammation and fibrosis of the bronchial wall, hypertrophy of the sub
mucosal glands and hyper secretion of mucus, and loss of elastic lung fibers and alveolar
tissue. Inflammation and fibrosis of the bronchial wall, along with excess mucus
secretion and destruction of elastic fibers, cause mismatching of ventilation and
perfusion. Destruction of alveolar tissue decreases the surface area for gas exchange, and
loss of elastic fibers, which normally provide traction and hold the airways open, impairs
the expiratory flow rate, increases air trapping, and predisposes to airway collapse.
The clinical manifestations of COPD usually have an insidious onset and patients
characteristically seek medical attention in the fifth or sixth decade of life, with
manifestations such as fatigue, exercise intolerance, cough, sputum production, or
shortness of breath. Persons with severe airflow obstruction may also exhibit use of the
accessory muscles, often sitting in the characteristic “tripod” position in which the arms
are braced to facilitate use of the sternocleidomastoid, scalene, and intercostals muscles.
Pursed-lip breathing enhances airflow because it increases the resistance to the outflow of
air and helps to prevent airway collapse by increasing airway pressure. Hypoxemia,
hypercapnia, and cyanosis develop, reflecting an imbalance between ventilation and
perfusion.
Treatment for COPD depends on the stage of the disease and often requires an
interdisciplinary approach. Pharmacologic treatment of COPD includes the use of
bronchodilators, including inhaled adrenergic and anticholinergic agents. Inhaled bagonists have been the mainstay of treatment of COPD for many years. Oral
theophylline may be used in treatment of persons who fail to respond to inhaled
bronchodilators. Oxygen therapy is prescribed for selected persons with significant
hypoxemia.
RK’s presenting symptoms for COPD included fatigue, and shortness of breath as well as
using the tripod position to aid in breathing. RK’s treatment consist of two bronchodilator
nasal sprays that she uses daily, as well as administered oxygen therapy of 3 liters per
minute through nasal cannula.
Dementia
Dementia or non normative cognitive decline can be caused by any disorder that
permanently damages large association areas of the cerebral hemispheres of subcortical
areas subserving memory and learning. Alzheimer disease most often presents with a
subtle onset of memory loss followed by slowly progressive dementia that has a course of
several years. Pathologically, there is diffuse atrophy of the cerebral cortex with
enlargement of the ventricles. The major microscopic features of Alzheimer disease are
the presence of neurotic plaques, neurofibrillary tangles, and amyloid angiopathy. In
persons with the disease, these plaques and tangles are found throughout the neocortex
and in the hippocampus and amygdale, with relative sparing of the primary sensory
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cortex. The hippocampus is crucial to information processing, acquisition of new
memories, and retrieval of old memories.
Alzheimer-type dementia follows an insidious and progressive course. The hallmark
symptoms are loss of short-term memory and denial of such memory loss, with eventual
disorientation, impaired abstract thinking, apraxias, and changes in personality and affect.
During the moderate stage there is extreme confusion, disorientation, lack of insight, and
inability to carry out the activities of daily living. Personal hygiene is neglected, and
language becomes impaired because of difficulty in remembering and retrieving words.
Behavioral changes can include agitation, sleep problems, restlessness and wandering,
aggression, and suspiciousness.
There is no curative treatment for Alzheimer dementia. Drugs are used primarily to slow
the progression and to control depression, agitation, or sleep disorders. Two major goals
of care are maintaining the person’s socialization and providing support for the family.
Psychotropic medications, such as antipsychotics and mood stabilizers, may be used to
assist in the behavioral management of the disease.
The patient shows the typical symptoms of dementia, she suffers from short and long
term memory loss with frequent disorientation. However her she is able to perform
personal hygiene at home and her language skills have not been disturbed. She suffers
from sleeping problems as well as moderate anxiety. Her current treatment at this time
consists of anti anxiety medication (Xanax).
Arthroplasty
Plastic surgery to reshape or reconstruct a diseased joint. This may be done to alleviate
pain, to permit normal function, or to correct a developmental or hereditary joint defect.
The procedure may require use of an artificial joint. Preoperative the patient is prepared
physically and emotionally for the procedure. Baseline data are gathered. Postoperative
the surgeon may prescribe traction or other immobilization devices, such as splints,
pillows, or casts, or a continuous passive motion device. Bed rest is maintained for the
prescribed period, and the patient is positioned as prescribed. The affected joint is
maintained in proper alignment, immobilization devices are inspected for pressure, and
frequent neurovascular and motor checks are performed on the involved extremity distal
to the operative site. Prescribed analgesics are administered, and the patient is taught
about self-administration. Noninvasive measures are employed to reduce pain and
anxiety. Vital signs are monitored for hypovolemic shock due to blood loss, and the
patient is assessed for other complications such as thromboembolism, fat embolism, and
infection. The incision is dressed according to protocol and assessed for local signs of
infection. Deep breathing and coughing, frequent position changes, and adequate fluid
intake are encouraged. The patient is assisted with prescribed exercise and activity, with
appropriate measures taken to prevent dislocation of the prosthesis and to reinforce
prescribed activity restrictions.
The patient was placed in a leg cylinder casts after surgery and there was a trapeze device
placed on her bed in order to aid in mobilization. Usage of pillows and an ice machine
has also been implemented into her care. The patient is to maintain bed rest until her
knee has heeled from surgery and can be anywhere from eight to twelve weeks.
Treatment for the patient consists of several prescribed analgesics including Morphine.
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Education on the use of incentive spirometer and deep breathing and coughing has been
given in order to prevent DVT and or pneumonia.
How well does the patient understand his/her medications and pathophysiology?
Although the patient verbalizes understanding of her medications and the pathophyiology
involved, when asked to repeat the aspects of her understanding she is not capable of
remembering her medications or what they have been described for.
How well does the patient manage his/her treatment regimens at home?
Because the patient has dementia, she is unable to manage her treatment regimens at her
home. However her husband has become her primary care provider and he has learned to
manage the patient’s treatments at home.
Nutritional/Metabolic
1. Fluids ordered for this patient:
No oral fluids ordered at this time.
2. IV fluids and rates:
0.45% NaCl with 2.5% Dextrose infused through 18 gauge in left anticubital space.
3. Diet which has been ordered for the patient:
Patient is on a regular with no restrictions diet.
4. Is the patient getting tube feedings? If so, what and how often:
Patient is not getting tube feedings at this time.
5. Finger stick blood sugar testing?
If so, how often:
Patient is not receiving blood sugar testing at this time.
6. Labs: Explain possible reason(s) for and the significance of lab values in regard
to nutrition:
 Basic Metabolic Panel- this blood test was performed to evaluate the patient’s
sugar level as well as fluid and electrolyte balance. Results of this test indicate the
patient’s body is able to maintain chemical metabolic reactions as all seven
substances tested were within normal ranges.
Why does the patient have his/her diet order?
The patient does not currently have her diet ordered for her.
How well is the patient eating?
During my care the patient ate 75% of her breakfast and lunch. It is documented in her
chart that she eats adequately.
Can the patient feed him/herself?
Patient is capable of feeding herself at all times.
Is the patient getting enough nutrition?
Yes the patient is getting enough nutrition; she is eating 75% of her meals.
Does the patient need to have a change in his or her diet order?
The patient does not need to have any changes on her diet at this time.
Does the patient have an NG tube? If so, is it to suction and how much drainage is
coming out?
The patient does not have an NG tube at this time.
List all nursing diagnoses related to nutrition/metabolism for this patient:
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Nausea related to postoperative symptom as evidence by patient verbalizes: “I feel sick to
my stomach and presence of gagging sensation.
Impaired skin integrity related to surgery as evidence by patient verbalizes pain at
surgical incision site and visual disruption of skin layers.
Risk for electrolyte imbalance related to loss of electrolytes associated with vomiting.
Risk for imbalanced fluid volume related to decreased oral intake associated with nausea
Risk for impaired skin integrity related to physical immobilization
Elimination
1. Does the patient need to have I & O documented?
Yes the patient’s I & O are being documented
2. Will the patient need to use a bedpan or bedside commode?
The patient does not need to have a bedpan or bedside commode at this time.
3. Labs: Explain possible reason(s) for and the significance of lab values in regard
to elimination:
 Blood Urea Nitrogen: Test performed to determine if kidneys are functioning
properly. Results of this test were within normal ranges indicated kidneys are able
to remove urea from the blood.
Bowel elimination pattern
Date of patient’s last bowel movement: 10/15/2013
Did the patient have constipation or diarrhea?
No complains of constipation nor diarrhea at this time.
Urinary elimination pattern
Did the patient get up to the bathroom? Use a bedpan? Bedside commode?
The patient is unable to ambulate and is using briefs.
Did the patient have a Foley catheter? Patent? Any signs of infection?
Patient has a 14 French Foley catheter, it was patent and there was no signs of infection.
Did the patient have at least 30 ml of urine out per hour?
The patient did have more than 30 ml urine output per hour.
Perspiration: excessive? No excessive perspiration noted.
If the patient is on I & O, why?
The patient’s input and output is being monitored to assess for dehydration and fluid
imbalances.
List all nursing diagnoses related to elimination for this patient:
Readiness for enhanced urinary elimination as evidence by patient expresses desire of
removal of Foley catheter.
Risk for constipation related to insufficient physical activity.
Activity/Exercise
1. Activity order for this patient:
The patient has been order to be in bed rest.
2. How many times will you plan to get this patient out of bed while you are caring
for him/her?
The patient will not be getting out of bed at this time.
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3. What will be the best time to get the patient up?
The patient can only get up when the doctor orders it.
4. Type of bath you plan for this patient:
The patient will be receiving a bed bath.
5. When do you plan to do mouth care?
Oral care for the patient will be performed after breakfast.
6. What is the plan for checking vital signs?
Vital signs are checked every hour per hospital protocol.
7. Labs: Explain possible reason(s) for and the significance of lab values in regard
to activity/exercise:
Which activities of daily living was the patient unable to perform? How did you
help?
Patient is unable to ambulate therefore she is unable to use the bathroom, shower, and has
needs aid in getting dressed.
What activity level did you implement? Why?
The patient is on bed rest therefore the only mobility she had was instructed by physical
therapy technicians.
What was the patient’s level of activity tolerance? How did the patient tolerate the
activity which you did with him/her?
The patient was not able to tolerate much activity. Physical therapy performed some
range of motion exercises with her but such exercises would increase her pain level
therefore only several minutes of activity were performed.
How much help does the patient need to move in bed? Get in a chair? Ambulate?
The patient requires some help moving in bed; she has a trapeze installed at the top of her
bed to aid her in moving in bed. The patinet requires help getting into a wheelchair if
necessary although her doctor has prescribed for her to be on bed rest. The patient is
unable to ambulate.
Does the patient need to use assistive devices for mobility? If so, which ones?
The patient uses a trapeze to aid in mobility in bed.
Was the patient at risk for falls? If so, what did you do about it?
The patient is at high risk for falls, this was documented in her chart. Implementations
performed to prevent falls were raising the bed rails and keeping the bed at lowest
position, placing a risk fall wrist band on the pt, pt was reminded frequently on using call
light.
What kind of bath/mouth care did you implement?
The patient was given a brief bed bath in the morning after breakfast. Oral care was also
performed after breakfast.
Were the patient’s vital signs within normal limits (WNL)? If not, what did you do
about it?
The patient’s vital signs were within normal limits.
List all nursing diagnoses related to activity/exercise for this patient:
Activity intolerance related to bed rest secondary to orthopedic surgery as evidence by
patient verbalized “I’m tired” and no desire to participate in activities. Patient becomes
short of breath by activities such as repositioning.
Decreased cardiac output related to altered heart conduction as evidence by patient
verbalized “I feel breathless sometimes”, and shows signs of restlessness.
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Fatigue related to anxiety and sleep deprivation as evidence by patient verbalized
perceived need for more rest and patient appears to be lacking energy.
Impaired gas exchange related to ventilation perfusion imbalance secondary to COPD as
evidence by patient verbalized “I feel breathless sometime”, and patient appears restless.
Impaired physical mobility related to muscufloskeletal impairment as evidence by patient
reports pain upon movement and has limited range of motion.
Ineffective airway clearance related to COPD as evidence by patient complains of
shortness of breath and use of oxygen 2L/min per nasal cannula.
Sleep/Rest
Which planned interventions may interfere with this patient’s sleep/rest?
The intervention of obtaining the patient’s vital signs every hour will definitely interfere
with the patient’s sleeping pattern and decrease her rest time.
How well did the patient sleep the night before you cared for him/her?
The patient states she did not get enough sleep the night before I cared for her. She states
she felt anxious as it was her first over night stay at the hospital.
How well is the patient resting during the day?
The patient was able to take frequent naps throughout the day and get more rest.
Did the patient have any signs of not having enough sleep/rest?
The patient appeared a bit restless earlier in the morning but after resting throughout the
day she no longer appeared restless.
What can be done to help the patient to rest better?
In order to help the patient sleep throughout the night, the nurse and other staff can set a
routine that requires minimum amount of sleep interruptions such as obtaining all vitals
and administering medications at the same time.
List all nursing diagnoses related to sleep/rest for this patient:
Disturbed sleep pattern related to care giving responsibilities as evidence by patient
verbalized “I didn’t really sleep a lot” as well as evident change in normal sleep pattern.
Sleep deprivation related to prolonged discomfort as evidence by patient complains of
anxiety and appears restless.
Readiness for enhanced sleep as evidence by patient expresses willingness to enhance
sleep and occasional use of medications to induce sleep.
Cognitive/Perceptual
Describe the patient’s level of consciousness (LOC):
Patient was someone alert, she was oriented to person but she was often confused as to
situation, place and time. Patient suffers from short term memory loss.
Vision and hearing status—any aids?
Patient wears reading glasses. Patient does not use any hearing aids.
Other sensory difficulties:
Is the patient at risk for falls? If so, what did you do about it?
The patient is at high risk for falls. Bed was kept at lowest position with the bed rails up.
The patient has a fall risk wrist band on. The patient was reminded on how to use the call
light.
Communication status—reading, writing, comprehension, language spoken,
Process Paper 16
Method of communication:
The patient’s primary language is English. She is able to read, write and comprehend it
efficiently.
Is there anything that will affect this patient’s ability to learn?
There are many aspects of the patient’s health that may act as barriers to her learning. She
is suffering from moderate pain, she in restless and fatigued, she suffers from anxiety and
she has difficulty remembering things.
Are there any cultural considerations to consider in regard to care of this patient?
Patient’s family stated they are active in the Lutheran religion and would like privacy
when performing prayer.
Was the patient experiencing pain? How much? What did you do about it? Did you
reassess pain after your interventions? Were the interventions successful?
At the time of assessment the patient rated her pain level at an 8 on a scale of 1-10. She
was able to localize her pain to her left knee and described it as dull and throbbing.
Interventions taken included further teaching and reminding the patient on proper use of
her PCA. PRN Morphine was also administered. Patient was also educated on non
pharmacological forms of therapy such as soft music and guided imagery. An hour after
administration of pain medications the patient’s pain level was assessed once again and
the patient rated it 3 out of 10. Interventions were successful.
List all nursing diagnoses related to cognition/perception for this patient:
Chronic confusion related to patient is over sixty years of age and suffers from severe
dementia as evidence by patient cannot identify her current situation, and becomes
agitated when finds herself confused.
Chronic pain related to degenerative joint disease as evidence by patient states she pain in
left knee for the past three years as well as uses guarding behavior towards affected limb.
Impaired memory related to neurological disturbances as evidence patient unable to recall
information, and observed experience of forgetting.
Self-perception/Role Relationships
How does the patient feel about his/her ability to function at home?
The patient suffers from dementia therefore she believes she is more than capable of
functioning normally at home; however it is her husband who performs all of the house
duties.
Will this illness affect the patient’s ability to function at home?
The patient’s total knee replacement will affect the patient’s ability to function at home.
If so, what will be affected and what needs to be done about it?
The patient is unable to perform activities of daily living such as bathing and dressing
without help therefore it was decided by her family along with her primary healthcare
provider that it is best that she goes to a rehabilitation center to fully recover before going
back home.
Who depends on this patient at home?
There are no persons who depend on the patient at this time.
Who is available to help this patient at home?
The patient’s husband is the person who takes care of the patient at home.
Who is in charge of discharge planning for this patient?
Process Paper 17
The floor nurse is in charge of discharge planning for this patient.
Will the patient need teaching in regard to needed changes in lifestyle (including
diet, exercise, medications, etc)? If so, what and why? Who will do the teaching?
The patient needs further education on the types of exercises she is encouraged to
perform in order to increase her ROM. The physical therapy team has and will continue
to do this teaching for the patient.
List all nursing diagnoses related to self perception/role relationships for this
patient:
Moderate anxiety related to threat to change in environment as evidence by patient
expressed concerns due to change in life events, as well as fear of unspecified
consequences to her health situation.
Disturbed body image related to surgery of lower extremity as evidence by patient
verbalized: “people are going to look at my leg and think I look weird” and constant
monitoring of the affected body part.
Sexuality/Reproduction
Does this illness have the potential to affect the patient’s sexuality?
The patient’s illness does not have a major potential in affecting her sexuality.
Did the patient express any concerns about the impact of this illness on his/her
sexuality? If so, what should be done to address the concerns?
The patient’s major concern is that her husband will not have enough time to visit her at
the hospital and that she may become lonely. The patient was given reassurance that she
would always be able to talk with the nurse whenever she felt lonely. This concern was
also described to the husband who also gave the patient reassurance that he would visit
her every day.
List all nursing diagnoses related to sexuality/reproduction for this patient:
Risk for loneliness related to social isolation.
Coping/Stress Management/Values/Belief Patterns
Being in the hospital is rough. How is the patient coping?
The patient has dementia, therefore when she forgets that she is hospitalized and then
remembers she has a difficult time understanding why she is there. However, if the
patient’s husband is present she seems to be able to cope with situation better and even
takes her less time to remember that she is at the hospital.
If the patient is not coping well, what did you do about it?
If the patient became agitated because she could not recall why she was hospitalized, then
I would talk to her in a soft calm voice and explain to her that she had surgery and she
was at the hospital recovering. Then I would allow for her to express her emotions and
answered any questions that she may had.
Are the patient’s spiritual needs being taken care of? How do you know? If not,
what did you do about it?
The patient along with her family expressed to me that they are active in the Lutheran
religion and that they had met with spiritual services and arranged for a person of their
Process Paper 18
religion to visit the patient at least once per day. This was documented in the patient’s
chart and I obtained confirmation from the spiritual services representative.
List all nursing diagnoses related to this functional health pattern for this patient:
Impaired individual resilience related to loss of autonomy as evidence by lower perceived
health status and depression.
Risk for impaired religiosity related to life transitions and depression.
III. General Head to toe assessment:
Vital signs: Blood Pressure: 130/70 Temperature: 97.3 Pulse: 60 Respiration rate: 16
O2 sat: 95%
LOC: Alert to person, confused often
Breath sounds: Diminished breath sounds auscultated on both lungs
Heart sounds: Regular and strong heart sounds and no murmurs heard.
Bowel sounds: Active in all four quadrants. No bruit present.
Moving all extremities? Not able to move lower left extremity Strength: Non affected
extremities had full strength and full ROM
Peripheral pulses: Regular 2+ expected
Skin integrity: Skin appears clean and with no lesions or breakage. Skin is warm to
touch and expected color throughout.
IV sites (where are they and how do they look/function): Patient has a peripheral 18
gauge, left anticubital IV. There is no tenderness or redness noted. Patient has no
complains.
Drains (Foley, surgical drains, etc.): Patient has a 14 French Foley catheter to drain
freely and secured to the leg. There is no redness or swelling noted. Patient has no
complains at this time.
Dressings (where, type, drainage, etc): Patient’s incision was closed with staples and
no dressings were needed.
Braden Score: 14
Other focused assessment:
IV. Developmental level of this patient
According to Erickson’s Theory of Development, the patient is currently in the Integrity
versus Despair stage. In this eight and final stage of development occurs from age 65 to
the end of life. During this time period, people reflect back on the life they have lived and
come away with either a sense of fulfillment from a life well lived or a sense of regret
and despair over a life misspent.
After having the pleasure of conversing with the patient about her life experiences, it was
very obvious to me that she was extremely content and satisfied with the way her life had
turned out. She successfully became a nurse and provided care for many years. She
married “the man of my dreams” and had three children who grew up to be successful
men. When asked if she had any regrets whatsoever, the patient responded that she has
lived the best possible life and that although difficult at times, she would not have it any
other way.
The patient is an individual who is full of integrity who has attained an incredible amount
of wisdom throughout her lifetime. She is incredibly strong and does not let her dementia
take over her amazing and caring personality.
Process Paper 19
V. Look at all of the nursing diagnoses from the above assessment. Prioritize the first 5
nursing diagnoses according to which are most threatening to the life and integrity of the
patient and/or family. Include a paragraph stating your rationale for prioritization.
1. Ineffective airway clearance related to COPD as evidence by patient complains
of shortness of breath and diminished breath sounds upon auscultation.
2. Acute pain related to degenerative joint disease as evidence by patient states
she pain in left knee for the past three years as well as uses guarding behavior
towards affected limb.
3. Impaired skin integrity related to surgical incision as evidence by patient
verbalizes pain at incision site and visual disruption of skin layers.
4. Activity intolerance related to bed rest secondary to orthopedic surgery as
evidence by patient verbalized “I’m tired” and no desire to participate in
activities. Patient becomes short of breath by activities such as repositioning.
5. Disturbed sleep pattern related to care giving responsibilities as evidence by
patient verbalized “I didn’t really sleep a lot” as well as evident change in normal
sleep pattern.
The diagnosis of ineffective airway clearance is at the top of my priority list
because maintaining a patent airway is vital to the patient’s life. Secondary to keeping the
patient breathing is treating them for their pain, especially if their perception of their pain
is very high, then it is the nurses’ job to make the patient comfortable. Treating impaired
skin integrity is crucial in preventing further skin breakdown and it is extremely
important that the nurse knows to assess for this. Activity intolerance is an important
diagnosis and goes along with knowing how to make the patient comfortable. Disturbed
sleep pattern is also important because it is contributing to the patient’s health status.
VI. Care Plan: make a plan of care for each of the 5 prioritized above nursing
diagnoses
Subjective and
objective data
that is
pertinent to the
nursing
diagnosis.
Nursing
Diagnosis R/T
& AEB or
AMB if
applicable
Short and long
term
measurable
and realistic
patient goals &
outcomes
Nursing
interventions
(Including all
assessments,
treatments,
medications)
Documented
rationale for
your
interventions
and references
Evaluation of
goals: achieved
or measurable
changes?
Subjective:
Patient
verbalizes “I
feel
breathless
sometimes”
Objective:
visual signs
of orthopnea
Ineffective
airway
clearance
related to
COPD as
evidence by
patient
complains of
shortness of
Short term:
patient will
maintain
airway
patency
throughout
the shift on
10/15/13.
Long term:
1. The nurse
will
frequently
assess airway
for patency.
2. The nurse
will educate
and
encourage
the patient to
1.
Maintaining
airway is
always first
priority.
(Doenges,
Moorhouse,
Murr. 2010).
2. Deep
breathing and
Short term
goal:
successfully
achieved.
The patient
maintained a
patent airway
throughout
the shift.
Process Paper 20
breath and
diminished
breath
sounds upon
auscultation.
Patient will
demonstrate
behaviors to
improve or
maintain
clear airway
by the time
of discharge.
perform
deepbreathing and
coughing
exercises.
3. The nurse
will
auscultate
lungs for
presence of
normal or
adventitious
breath
sounds.
4. The nurse
will
encourage
different
positions
such as
sitting up,
head of the
bed at 45
degrees, as
tolerated.
coughing
allows for
improvement
of
productivity
of the cough.
(Doenges,
Moorhouse,
Murr. 2010).
3.
Auscultation
may indicate
presence of
any major
airway
obstruction.
4. Positioning
will promote
better lung
expansion
and improve
air exchange.
(Doenges,
Moorhouse,
Murr. 2010).
Long term:
successfully
achieved. The
patient
verbalized
understanding
of importance
of
maintaining a
clear airway
at all times.
Subjective
and objective
data that is
pertinent to
the nursing
diagnosis.
Nursing
Diagnosis R/T
& AEB or
AMB if
applicable
Short and long term
measurable and
realistic patient
goals & outcomes
Nursing
interventions
(Including all
assessments,
treatments,
medications)
Documented
rationale for
your
interventions
and references
Subjective:
Patient
rated her
pain at a
level 8 on
a scale of
1-10, were
10
represents
the worst
pain ever
felt.
Objective:
Patient
was
grimacing,
Acute pain
related to
degenerative
joint disease
as evidence
by patient
states she
feels pain in
left knee for
the past
three years
as well as
uses
guarding
behavior
towards
Short term:
Patient will
report pain is
relieved or
controlled by
the end of the
shift on
10/16/13.
Long term:
Patient will
understand and
follow the
pharmacological
regimen
prescribed by
the time of
1. The nurse
will assess all
aspects of the
pain.
2. The nurse
will review the
patient’s pain
flow sheet and
medication
administration
record to
evaluate
effectiveness of
pain relief.
3. The nurse
will educate on
1. This will
allow for
understanding
of all pain
factors.
Evaluation of
goals: achieved or
measurable
changes?
Short term goal
successfully
achieved.
Patient
verbalized relief
(Doenges,
of pain after
Moorhouse,
administration
Murr. 2010).
of medications.
2. This allows
Long term:
for evaluation
successfully
of medications.
achieved.
(Doenges,
Patient and her
Moorhouse,
husband both
Murr. 2010).
verbalized
3. This
understanding
provides the
of the
patient will
Process Paper 21
moaning
affected
and crying. limb.
alternative
the use of non
pharmacological options of
treatment.
approaches.
discharge.
prescribed
pharmacological
regimen.
Subjective
and objective
data that is
pertinent to
the nursing
diagnosis.
Nursing
Diagnosis R/T &
AEB or AMB if
applicable
Short and long
term measurable
and realistic
patient goals &
outcomes
Nursing
interventions
(Including all
assessments,
treatments,
medications)
Documented
rationale for your
interventions and
references
Evaluation of
goals:
achieved or
measurable
changes?
Subjective:
patient
states: “my
leg hurts
but it also
itches.”
Objective:
Disruption
of skin
integrity at
the lower
extremity.
Impaired skin
integrity
related to
physical
immobilization
as evidence by
patient
verbalizes pain
at incision site
and visual
disruption of
skin layers.
Short term:
patient will
preventative
measures and
treatment
program by
the end of the
shift on
10/16/13.
Long term:
The patient
will display
timely
healing of
skin wound
without
complications
by the time of
discharge.
1. The
nurse will
assess
blood
supply and
sensation
of affected
area.
2. The
nurse will
use
appropriate
barrier and
skinprotective
agents.
3. The
nurse will
provide
optimum
nutrition,
and
increase
protein
intake.
4.
1. To evaluate
actual/potential
for impairment
of circulation
to lower
extremity
Short term:
successfully
reached.
The patient
participated
in
preventative
treatments
mentioned
without
complains
or
resistance.
Long term:
Still in
progress.
Patient’s
skin is still
continuing
to heal.
(Doenges,
Moorhouse,
Murr. 2010).
2. To protect
the wound and
surrounding
tissues
(Doenges,
Moorhouse,
Murr. 2010).
3. This will
provide
positive
nitrogen
balance to aid
in skin and
tissue healing
and to
maintain
general good
health
(Doenges,
Moorhouse,
Murr. 2010).
Subjective and
objective data
that is
pertinent to
the nursing
Nursing
Diagnosis R/T
& AEB or
AMB if
applicable
Short and
long term
measurable
and realistic
patient goals
Nursing
interventions
(Including all
assessments,
treatments,
Documented
rationale for
your
interventions
and references
Evaluation of
goals: achieved
or measurable
changes?
Process Paper 22
diagnosis.
Subjective:
patient
verbalized:
“I get tired
easily.”
Objective:
Patient
becomes
short of
breath upon
exertion.
Patient
complains
of fatigue.
Activity
intolerance
related to
bed rest
secondary to
orthopedic
surgery as
evidence by
patient
verbalized
“I’m tired”
and no
desire to
participate in
activities.
Patient
becomes
short of
breath by
activities
such as
repositioning
& outcomes
medications)
Short term:
Patient will
participate
in desired
and
necessary
activities
by the end
of the shift
on
10/16/13.
Long term:
Patient will
learn
techniques
to enhance
activity
tolerance
by the time
of
discharge.
1. The nurse
will assess the
patient’s level
of mobility.
2. The nurse
will adjust
activities to
prevent
overexertion.
3. The nurse
will provide a
positive
atmosphere,
while
acknowledging
difficulty of
the situation of
the client.
1. This aids
in defining
what the
patient is
capable of
doing
(Doenges,
Moorhouse,
Murr. 2010).
2. This will
allow the
patient to
conserve
energy
(Doenges,
Moorhouse,
Murr. 2010).
3. This
intervention
helps to
minimize
frustration
and
rechanneled
energy
(Doenges,
Moorhouse,
Murr. 2010).
Short term:
Successfully
achieved.
The patient
was able to
participate
in both
necessary
and desired
activities
such sitting
up and
participating
in physical
therapy
exercises.
Long term:
Still in
progress.
The patient
is
continuously
learning
how to
enhance her
activity
tolerance.
.
Subjective
and objective
data that is
pertinent to
the nursing
diagnosis.
Nursing
Diagnosis R/T &
AEB or AMB if
applicable
Short and long
term
measurable and
realistic patient
goals &
outcomes
Nursing
interventions
(Including all
assessments,
treatments,
medications)
Documented
rationale for
your
interventions
and
references
Evaluation of
goals: achieved
or measurable
changes?
Subjective:
patient
complains
of being
awaken too
many
times
during the
night.
Objective:
Change in
Disturbed
sleep pattern
related to care
giving
responsibilities
as evidence by
patient
verbalized “I
didn’t really
sleep a lot” as
well as evident
Short term:
the patient
will identify
individual
interventions
to promote
sleep before
bedtime on
10/16/13.
Long term:
The patient
1. The nurse
will assess
environmental
factors that
interrupt
sleep.
2. The nurse
will consider
implementing
a sleep
protocol for a
1. Helps
identify
specific
causes that
interrupt
sleep; that
way they
can be
changed or
avoided
(Doenges,
Short term:
successfully
achieved.
The patient
identified
that listening
to soothing
music before
bedtime
would help
her fall
Process Paper 23
normal
sleep
pattern.
Patient
appears
restless.
change in
normal sleep
pattern.
Sleep
deprivation
related to
prolonged
discomfort as
evidence by
patient
complains of
anxiety and
appears
restless.
will
implement a
sleep
promotion
routine by
the tie of
discharge.
regular sleepwake routine
at the
hospital.
3. The nurse
will keep the
environment
quiet and
soothing as
well as using
bedding
supportive of
comfortable
body
alignment.
Moorhouse,
Murr.
2010).
2. An
established
protocol
will allow
for longer
periods of
interrupted
sleep
(Doenges,
Moorhouse,
Murr.
2010).
asleep faster.
Long term:
still in
progress.
The patient
is working
on
establishing
a routine that
will help her
obtain better
sleep in the
care
environment.
3. This
promotes
physical
comfort
and
enhances
relaxation
(Doenges,
Moorhouse,
Murr.
2010).
VII. Include a paragraph summarizing your care of this patient.
My care for this patient initiated the morning of 10/16/13. After report was given, I took
the time to personally introduce myself and establish rapport with the patient. In the
morning she appeared anxious and upon speaking with her she reported of not obtaining
good sleep the previous night. It was then decided that the patient needed to obtain as
much rest during the day as possible. After morning medications were passed, I
performed a head to toe assessment on the patient. Upon assessment I was able to learn
how the presenting health problem was affecting the patient’s overall status. I was also
able to learn from her husband about extensive previous health care history; as well as
listen to the patient’s personal life stories. Overall my experience in caring for this patient
was a very educational and life changing experience. Not only was I able to give top
quality care and comfort to a patient but at the same time I was able to learn very
valuable life lessons that will influence my practice as a future nurse.
Process Paper 24
Sources
Doenges, M., Moorhouse, M., & Murr, A. (2010). K. DePaul (Ed.), Nurse's pocket guide
diagnoses, prioritized interventions, and rationales (12 ed.). philadelphia, PA,
USA: F.A.Davis.
Porth, C.M. (2007). Essentials of pathophysiology: Concepts of altered
health status (2nd ed.). Milwaukee, WI: Lippincott Williams & Wilkins.
(2001). D. Venes (Ed.), Taber's cyclopedic medical dictionary (19 ed.). philadelphia, PA,
USA: F.A.Davis.