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This assignment requires NURSING Knowledge and Nursing Diagnosis Book 11th edition
Instructions: Answer the following questions.
Remember the acronym: ADPIE. Name and define each step of the nursing process.
Nursing Process Scenarios:
Complete the steps below for scenarios 1 – 6. Stay focused only on the information provided in the scenarios.
1. Highlight important information from each case as part of the Assessment.
2. Use that data to develop a Nursing Diagnosis.
a. Select a significant problem (nursing diagnosis) that the patient is evidently experiencing. Must use a NANDA approved nursing diagnosis.
b. State what the cause of the above problem is (related to factor) (R/T).
c. State the signs and symptoms (manifestations) (AEB) of the significant problem you have selected. When specifying the signs and symptoms, state only what you observe or see in relation to the problem.
3. From the nursing diagnosis, write a Plan that includes a smart goal (short-term goal) for each problem identified.Short-term should be achievable within 48 hours or sooner for this exercise.
4. For each goal of the plan, identify two nursing interventions to be Implemented. (This means: what can YOU do as a nurse, not looking for referrals or physician orders.)
Scenarios:
Scenario 1:
Mr. Ford has arrived on your ward from the Emergency Department. He has been diagnosis as having a CVA and has suddenly become incontinent with frequent episodes overnight. He is now very drowsy, difficult to rouse and dysphasic since the CVA.
Scenario 2:
Mr. Warren has been admitted with pain following falling and fracturing his right arm. He is grimacing and holding his arm and rates his pain 6/10. He is unable to use his arm to feed himself.
Scenario 3:
Mrs. Scott is 93 years of age and has been admitted after being found collapsed at home. Until then she was reported to be well. She presents with poor skin turgor, a dry tongue, having not taken fluid for an estimated four days.
Since the fall she is not oriented to person, place, or time. The medical staff believe that, as a Diabetic, she had a hypoglycemic episode. As a result of lying in the one spot for so long, she has a stage one pressure area sore on her hip.
Scenario 4:
Mr. Woods is short of breath, anxious, cyanosis, disoriented to person, place, and time, and has a respiratory rate of 40. All of these symptoms began yesterday when he suddenly found it difficult to breathe.
Scenario 5:
Mr. Sampson is 83. He is admitted following a fall at home. His weight is low at 46kg. He has no teeth or dentures.
Scenario 6:
Mr. Johns has been admitted with a stage 1 pressure sore. He is incontinent and cannot use a urinal because of contractures of his lower limbs.