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Case study -Ncp

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Name: Mrs. MM Age: 77 years old
Nursing Diagnosis: Anxiety related to chronic illness w/ changes in roles/ body image.
Medical Diagnosis: ESRD secondary to DM Nephropathy
Short-term Goal: At the end of my shift, patient will verbalize acceptance of self in situation.
Long-term Goal: At the end of hospitalization, patient will demonstrate adaptation to changes or events that have
occurred.
Cues:
Problem
Scientific Rationale
Nursing
Interventions
Rationale
Evaluatio
n
Body
malaise
Blurred in
vision
Restlessne
ss
ANXIET
Y
Anxiety is a normal experience.
Moderate or high level of anxiety
can increase alertness and
performance in particular
situations. However, people who
experience continues or
recurring fears or episodes of
intense fear can feel powerless
to manage their symptoms and
their lives can become severely
restricted.
http:/www.panicanxietydisorder.
org au /index.htm
Assessed
level of fear
of client.
Helps
determine
the kind of
intervention
s required.
Fear of
unknown is
lessened
by
information
& may
enhance
acceptance
of
permanenc
e of ESRD
and
necessity
for dialysis.
Goal met.
Patient
verbalized
acceptanc
e of self in
situation.

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Name: Mrs. MM Age: 77 years old
Medical Diagnosis: ESRD secondary to DM Nephropathy
Nursing Diagnosis: Altered Fluids & electrolytes r/t Urinary retention as evidence increase K & decrease Na.
Short term Goal: At the end of my shift, patient will be able to increase urine output at least 1500cc in 24 hrs.
Long term Goal: At the end of hospitalization, the patient will be able to have a normal urine output & voiding pattern.
Provided
opportunitie
s for client
to ask
questions &
verbalizatio
n of
concern.
Creates
feeling of
openness &
cooperation
& provides
information
that will
assist in
problem
identificatio
n/ solving.

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Name: Mrs. MM Age: 77 years old Nursing Diagnosis: Anxiety related to chronic illness w/ changes in roles/ body image. Medical Diagnosis: ESRD secondary to DM Nephropathy Short-term Goal: At the end of my shift, patient will verbalize acceptance of self in situation. Long-term Goal: At the end of hospitalization, patient will demonstrate adaptation to changes or events that have occurred. Cues: Problem Scientific Rationale Nursing Interventions Rationale Evaluation Body malaise Blurred in vision Restlessness ANXIETY Anxiety is a normal experience. Moderate or high level of anxiety can increase alertness and performance in particular situations. However, people who experience continues or recurring fears or episodes of intense fear can feel powerless to manage their symptoms and their lives can become severely restricted. http:/www.panicanxietydisorder.org au /index.htm Assessed level of fear of client. Explained procedures/ care as delivered. Repeated explanation’s frequently as needed. Provided opportunities for client to ask questions & verbalization of concern. Helps determine the kind of interventions required. Fear of unknown is lessened by information & may enhance acceptance of permanence of ESRD and necessity for dialysis. Creates feeling of openness & cooperation & provides information that will assist in problem identification/ solving. Goal met. Patient verbalized acceptance of self in situation. Name: Mrs. MM ...
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