NURS 121L West Coast University Nursing Process Worksheet

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Whyvr74011

Health Medical

Nurs 121L

West Coast University

NURS

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Please read the scenario and answer the questions. Upload the scenario with your answers and place it under week 1 nursing process worksheet. We will go over the scenario during pre conference next week. Fill out the worksheet using the report

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Course: NURS 121L-A NURSING PROCESS WORKSHEET Date: ____________________________________________________________________________________ Student Name: Faculty Name: Instructions: Each clinical day each student will develop a nursing process outline for one patient of their choice. These are quick writes and should be done throughout the shift and not taken home. These will be discussed in post conferences with the faculty. The outline will be as follows: Assessment (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Obj:_______________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Subj:_______________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Nursing Diagnosis (2) Must be prioritized. Must be Nanda using three part statement (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Stem (DX): Etiology (Cause) : as evidenced by (Signs and symptoms) Abnormal Assessment Findings. (1)________________________________________________________________________________________ __________________________________________________________________________________________ (2)________________________________________________________________________________________ __________________________________________________________________________________________ Planning (Patient goals) Must be SMART goals Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain) by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.) ___________________________________________________________________________________________ ___________________________________________________________________________________________ Implementation (Specific nursing interventions that were performed during your shift): Must contain the following: Assess {observe, palpate, percuss}; Monitor; Administer; Collaborate w/ specific multi-disciplinary team; & Teach ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Page 1 of 2 Course: NURS 121L-A NURSING PROCESS WORKSHEET Evaluation (What was the outcome: Goal; Met or Not met or Partially met and How to revise.) ___________________________________________________________________________________________ ___________________________________________________________________________________________ Nursing Application Assessment Include activities throughout the day performed in relation to the following NCLEX content categories. See content category examples below as cited by NCSBN Management of Care ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Safety and Infection Control ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Basic Care and Comfort ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel. Related content includes, but is not limited to: Advance Directives. Advocacy, Assignment, Delegation and Supervision, Case Management, Client Rights, Collaboration with Interdisciplinary Team, Concepts of Management, Confidentiality/Information Security, Continuity of Care, Establishing Priorities, Ethical Practice, Informed Consent, Information Technology, Legal Rights and Responsibilities, Performance Improvement (Quality Improvement), Referrals Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards. Related content includes, but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic Principles, Handling Hazardous and Infectious Materials, Home Safety Reporting of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living. Related content includes, but is not limited to: Assistive devices, Elimination, Mobility/Immobility, NonPharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest and Sleep Page 2 of 2 Pt. Mcdonald, Mary Admission date: 11/5/2020 Age: 52 Allergies: Milk, Morphine Code Status: Full Code DX: Bowel Obstruction HX: Chron’s disease, C-diff, colostomy ER note: Pt came to the hospital from home, complaining of ABD pain, N/V, pt. States she has not eaten X2 days, pt. Has a stoma which was placed in 2017, pt. States she was taking Tylenol with no relief, Ct scan ordered and results showed an abdominal blockage and plans is to do a surgical intervention to replace the stoma which is scheduled later this afternoon. Current vital signs: HR 98, Resp. 22, O2 sat 98% on room air, BP 140/80 Things to think about! We will discuss this next week What labs would be very important for this pt.? Take into consideration the pt. Is also going to surgery today. Do you need any cultures for this pt. Or any other diagnostic tests? What consults would benefit this pt. After surgery? Medications ordered (Please look at these meds and get an idea why the patient is prescribed them also look for any big side effects) Protonix 40 mg IVP q day NS @ 75 cc an hour continous Diluidid 1 mg IVP every hour for pain prn Zofran 4 mg IVP every 8 hours as needed Cefazolin 1 gram IVPB q 8 hours Reglan 10 mg IVP q 6 hours Metamucil 1 tsp q 8 hours q day Tylenol 325 mg every 4-6 hours prn for mild pain and fever >101.1
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Explanation & Answer

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Course: NURS 121L-A
NURSING PROCESS WORKSHEET

Date: ___________________________________________________________________
Student Name:
Faculty Name:

Page 1 of 8

Course: NURS 121L-A
NURSING PROCESS WORKSHEET

Instructions:
“Each clinical day each student will develop a nursing process outline for one patient of their
choice. These are quick writes and should be done throughout the shift and not taken home. These
will be discussed in post conferences with the faculty.” The outline will be as follows:
“Assessment (Based On Systems: Cardio, Resp, GI/GU, Mobility, Neuro, Safety, Skin, Pain,
Psychosocial)”
Objective
i.

Appearance: Generally, the client appears distressed and sunken eyes.

ii.

Vitals: She has a high-grade fever of 101.2F, tachypnea (22 beats per minute), and
hypertension (140/80 mmHg).

iii.

Pain: The client reports pain of 7 out of 10 on the pain assessment scale.

iv.

Respiratory: Assessment of the lungs revealed cough, normal chest expansion, and absence
of adventitious sounds.

v.

Cardiovascular: Assessment of the heart revealed a heart murmur.

vi.

Integumentary: Assessment of her skin reveals dry mucous membranes suggestive of
dehydration.

vii.

Gastrointestinal: Assessment of her abdomen reveals abdominal scarring from a colostomy,
palpable abdominal mass from impacted feces, hernia, distension, tenderness, and
peritoneal signs, including rebound tenderness and guarding (Baiu & Hawn, 2018).

viii.

Musculosk...


Anonymous
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