Complete The nursing process worksheet using the scenario Mr. Adams…
Question Answered step-by-step Complete The nursing process worksheet using the scenario Mr. Adams… Complete The nursing process worksheet using the scenario Mr. Adams is a 58-year and man who admitted to the emergency room with acute chest pain. The patient states, “My pain feels like its crushing my chest and it goes down to my right shoulder and jaw.” Upon admission, he was observed to be clammy, pale and extremely anxious. Recorded vital signs were BP 160/90, P 134/min Respiratory rate 12/ min and oxygen saturation on room air 91%. Patient complained of “I am short of breath when resting.” The patient also complained being nauseated. Social history: Mr. Adams is accompanied by a colleague from his work. Social history includes being married with two grown daughters, age 18 and 20. His wife is being treated for depression. He is presently employed as a business executive. He is concerned about his wife’s response to his current condition. Upon assessment at 1400 hours his BP was recorded as 110/60, P 62 beats per min. ST elevation was noted on the ECG. His chest pain has worsened. Temp 97.1 T. Patient rates pain 10 out of 10. Medications amlodipine and Losartan iHistory of Present Illness: Pathophysiology of Admitting Diagnosis – Must include pathophysiology, signs & symptoms, risk factors, complications Priority Nursing Problem (2) Must be prioritized problem using three part statement (based on abnormal assessment findings) Problem#1Priority Problem ? Related To: Etiology (Cause) ? As evidenced by: signs and symptoms from assessment Nursing Risk for Priority Problem (1) – Must be priortized problem using three part statement (based on assessment findings) Risk for Problem#1″Risk for…” Problem ? Related To: Etiology (Cause) Planning/Patient Goals: 1 for each nursing priority problem (3 total) Problem #1 Goal Must be SMART (Specific, Measurable, Achievable, Realistic, Timeframe) and start each with “Pt. will… ” Problem #2 Goal Implementation – Specific nursing interventions that were performed during your shift (Must have 3 per priority problem) Rationale:Interventions for Priority Problem #1 Rationale:Interventions for Priority Problem #2 Interventions for Priority Risk for Problem #1Evaluation – What was the outcome? Goal met | Goal not met | Goal partially met and how to revise/recommend 1. 2. 3. Must have 1 evaluation per goal Nursing Application Assessment 1. 2. Include activities throughout the day performed in relation to the following NCLEX content categories. See content category examples below as cited by NCSBN 1. 2. Safety and Infection Control Basic Care and Comfort 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, Non-Pharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest and Sleep Health Science Science Nursing NURS 120 Share QuestionEmailCopy link Comments (0)
