Question: Scenario: Daniel, a 73 years old, came to the Scenario Daniel, a 73 ye

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Question: Scenario: Daniel, a 73 years old, came to the Scenario Daniel, a 73 years old, came to the emergency room with a temperature of 100.2 F. He complained of abdominal pain. He rated the pain at 10 on a scale of 1-10. He was admitted and diagnosed with urinary tract infection and urosepsis. Past medical history includes prostate cancer Daniel about 3 weeks. It was removed last week. The RN obtained only 30 mL of dark brown urine, with no visible blood noted when the patient was catheterized with an 18 Fr Foley catheter in the emergency room. Daniel reported that he has not been drinking fluids because it hurts when try to go. He reported not unintentional weight loss or gain of 10 pounds or greater. Upon inspection, no visible edema. Upon palpation, no edema noted. A saline lock was placed in the left forearm for antibiotic therapy, it is patent and free of signs of infection. reports incontinence related to having a indwelling foley catheter during chemotherapy for Answer the following questions. Question 1 The nursing process is a valuable tool for RN to use in practice to ensure the best possible care for your patients. Assess and observe both physiologic and psychological needs of the patient. Describe the problem and provide supporting data for its identification Focus on problems that are controllable Use outcome (NOC) to identify goals that are plausible and measurable Use scientific principles and rationale to develop alternative courses of actions Perform safe and effective nursing care Document the effectiveness of the plan of care for the individual patient based on current problems and abnormal signs and symptoms Develop nursing diagnoses based on facts and supporting data according to NANDA Use interventions (NIC) to identify nursing interventions in response related to the nursing diagnoses Establish a plan of care outlining appropriate independent, dependent andlor interdependent nursing actions based on assessment data and analyis for goual attainment Evaluate extent to which goals had been achieved Review, modify, or resolve plan of care Question 2 Underline all the cues and problems in the scenario. Cluster the relevant data into groups. Identify and prioritize 3 nursing diagnosis What goal or goals do you expect for this patient

Explanation / Answer

The nursing diagnosis, NIC and NOC are standardized languages in formulating a nursing care plan. It improves communication, provides continuity of care, improves effectiveness and acts as a strong research base. Nursing diagnosis is the clinical judgment of actual or potential problems with patient, family or community. There are three types of nursing diagnosis: actual, risk and wellness diagnosis. The components of nursing diagnosis are a label, related factors and defining characteristics.

NOC indications help in measurement of effective interventions. The components are the label (name used to describe the character), an indicator of patient behaviour and a five-point scale to assess patient status.

NOC: Assess based on 1 to 5 scale

1- Severely compromised

2- Substantially compromised

3- Moderately compromised

4- Mildly compromised

5- Not Compromised

NIC are the nursing interventions is the description of nursing actions. Its components are name, definition and set of actions.     

Immune status – 0702

Body temperature, WBC values, Skin and mucosa integrity, GI function, recurrent infection, weight loss, tumours

NICs: Infection protection 6550, Nutrition management 1100, Skin surveillance 3590, Surveillance 6650, Wound care 3660

Infection severity -0703

Nutritional status- 1004

Tissue integrity – skin and mucous membrane – 1101

Physiologic problems:

Pain, 10 out of 10 in pain scale

Hyperthermia, body temperature of 100.2F

Weight gain or loss. More than 10 pounds

Decreased urine output, Less than 30 ml, dark brown urine

Decreased fluid intake, patient said that he is not drinking because it hurts when try to go

Potential problems:

Risk for infection due to indwelling catheter and saline lock

Psychological problems:

Fear

Anxiety

Knowledge deficit

NANDA diagnosis, NOC and NIC

1. The risk for Infection (progression from sepsis to septic shock) related to the development of opportunistic infections as evidenced by the presence of saline lock, hyperthermia and indwelling catheter.

NOC: 0703 Infection Severity (1-5 scale) and associated symptoms

Skin and mucus integrity, GI function, Temperature, weight loss recurrent infection

NIC: 6550 Infection Protection

Prevention and early detection of infection in a patient at risk

Assess vitals

Wound care

Pharmacologic measures – antibiotics

WBC count

Follow aseptic technique

2. Pain related to inflammation secondary to urosepsis as evidenced by patients verbalization and pain scale measurement of 10 in 1-10 point scale

NOC:

1306 Pain: Adverse Psychological Response

Severity of observed or reported adverse cognitive and emotional responses to physical pain

1605 Pain Control

Personal actions to control pain

2101 Pain: Disruptive Effects

Severity of observed or reported disruptive effects of chronic pain on daily functioning

2102 Pain Level

Severity of observed or reported pain

NIC: 1400 Pain Management, Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient

Assess the characteristics of pain.

Comfortable position

Reassurance

Analgesics

3. Fluid volume deficit related to decreased fluid intake as evidenced by patients verbalization of decreased drinking in fear of pain.

NOC: 0601 Fluid Balance, Water balance in the intracellular and extracellular compartments of the body

NIC: 1100 Nutrition Management

Assisting with or providing a balanced dietary intake of foods and fluids

1120 Nutrition Therapy

Administration of food and fluids to support metabolic processes of a patient who is malnourished or at high risk for becoming malnourished

2080 Fluid/Electrolyte Management

Regulation and prevention of complications from altered fluid and/or electrolyte levels

4120 Fluid Management

Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels

4130 Fluid Monitoring

Collection and analysis of patient data to regulate fluid balance

4140 Fluid Resuscitation

Administering prescribed intravenous fluids rapidly.

Another diagnosis:

Risk for shock related to infection

Risk for deficient fluid volume related to massive vasodilation

Risk for impaired gas exchange related to interference with oxygen delivery

Fear related to unknown outcome of disease and intolerable pain as evidenced by patient’s verbalization

Knowledge deficit related to deficiency of information related to the topic as evidenced by increased number of doubts

References :

1.Iowa Intervention Project (2008). Nursing interventions and Classification (NIC). (4th ed.) St. Louis: Mosby, Inc.

2.Iowa Outcomes Project (2008). Nursing outcomes classification (NOC). (3rd ed.) St. Louis: Mosby, Inc.

3. NANDA Nursing Diagnosis: Definitions and Classifications 2009-2011. (2009). Indianapolis, IN Wiley-Blackwell.

Cues in the scenario:

Age- 73 years

Temperature: 100.2F

Abdominal pain, 10 in 1- 10 points scale

History of prostate cancer

Decreased fluid intake, verbalisation

Urine output of 30 ml, dark brown

Weight gain or loss of 10 pounds

No palpable or visible edema

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