Nur402 Week 2 Nursing Process Paper
Nursing Process Paper
Melissa Wilcox
Grantham University
Transition to Pro Nursing
NUR402
Margaret McGannon
June 23, 2013
Nursing Process Paper
The family I will be assessing consists of four people living in the household. First is the grandmother who is 99 years old, her daughter who is 77 years old, and her son who is 50 years old and finally his son who is 17 years old. The grandmother of this family came to live in this household 6 years ago after she was unable to live by herself anymore. The mother of this house lived here with her husband until he passed away 4 years ago. Her son and grandson have always lived with them as well. He is a single dad and has raised his son alone for the past 10 years.
This is a Caucasian family living on a very limited fixed income. The …show more content…
grandmother receives her social security as income, the mother receives her social security as income and also her deceased husband’s pension, the son works sporadically as a maintenance man for the housing development they live in, and the grandson is in high school and does not work. They rent this apartment through a family member who charges them a reasonable monthly fee of $1000 for a three bedroom apartment. This family has lived here for over 30 years.
The 99 year old grandmother has many disabilities. She unable to walk short distances and is wheelchair bound. She is still able to walk to the bathroom from the kitchen but no further. She sleeps in the bedroom closest to the kitchen and the bathroom so the transferring is easier. She is legally blind and her sight is continually degenerating. Her hearing is also very poor and growing increasingly worse. She has been an insulin dependent type 2 diabetic for over 50 years. She is not very compliant with a diabetic diet or with checking her blood sugars regularly since she is unable to check it herself and does not prepare her meals for herself anymore. She depends on her daughter for mostly all her day to day needs. She needs assistance with filling her insulin syringes since she cannot see to measure the amount, but she is still able to administer the insulin herself in her abdomen. She has Congestive Heart Failure and is on many different medications. She has a pacemaker that was put in 6 years ago. She does regularly see her primary medical doctor once a month although it is getting very difficult for her to get to the appointments because she cannot walk very far at all. Even the short distances like to the bathroom make her very short of breath. She has had several gastrointestinal surgeries which affect her digestion and elimination process. She becomes constipated at times and uses an enema to assist in moving her bowels. She is overweight and has significant swelling in her lower extremities due to the CHF. Skin in dry but intact, she occasionally has a fungal rash under her abdomen under excess skin. She gets frequent urinary tract infections. She is continent but wears adult diapers for leakage or accidents. She receives home health care three times a week for a bed bath and light nursing care.
Her physical health is deteriorating significantly from her age and also her medical illnesses. Her mental health is still very much intact however she is very depressed and lonely most of the time. I think her stress level in high because she doesn’t want to feel like a burden to her daughter and her son. I think she feels unwanted there at times and that she also feels like she has nowhere else to go. There are no other family members that could take her in permanently due to work schedules and the ability to care for her.
She has no chemical substance abuse, in fact she is opposed to taking anything except Tylenol for pain which she has chronically. She suffers from severe arthritis pain in her neck, back, hips, and knees. She also complains of severe pain from hemorrhoids that are very large and cause pain when sitting. She refuses to take any form of narcotic or pain medicine because she doesn’t want to “get addicted”. She does not drink or smoke cigarettes.
Her daughter also has several health issues but is still very active and reasonably healthy. Her vision is manageable with glasses and her hearing is intact. She is also a type 2 diabetic but it is controlled with diet and medication. She takes blood pressure medication to manage her hypertension. She does not work and only drives very occasionally. She follows up with her doctor regularly. Her physical and mental statuses are well intact. Her stress level is very high at times due to the constant care she has to provide for her aging mother. At times she gets very frustrated being the sole caretaker of her 99 year old mother and lashes out in anger.
Her son living in the home has poor eyesight, no hearing in the left ear and also diabetic however he is not being treated by a physician or compliant with a diabetic diet. His education level is only 2 years of high school and does not have steady employment. He and his son rely on the income of his mother and grandmother to support them. His son is a teenager and is following in his father’s footsteps of being a poor student and lack of work ethic. He does not contribute to the family for income or help out around the house. There is questionable chemical substance abuse for him. He does not interact with the family and has a bad attitude most of the time.
To summarize, this family unit is dependent upon the elderly grandmother who is unable to care for herself anymore and her daughter who is under a great deal of stress from becoming the caretaker for her mother. There is little support from other family members. This is not because they don’t care or unwilling to help but because of their own busy lifestyles. The health risks for these two women are high but they are routinely getting medical checkups. Their medical coverage is through Medicare and most of their medical needs are met though this health care plan.
Nursing Diagnoses Statements
I will be concentrating on the grandmother of the household to create Nursing Diagnoses.
Physically, grandmother is 99 years old and suffers from severe arthritis and bone degeneration. She does not sit or sleep comfortably in her wooden kitchen chair or bed. 1. Chronic Pain related to severe arthritis and bone degeneration as evidenced by inability to move joints easily, difficulty walking, and trouble sitting or sleeping in one position.
Psychologically grandmother is depressed and has feelings of being alone and hopeless most of the time. She feels like a burden to her family for having to take care of her. 2. Risk for loneliness related to minimal family support and dependence on her daughter to be her caregiver. As evidence by bouts of depression and crying, feelings of sadness and hopelessness.
Safety issues have been a problem and continue to put her at risk. 3. Risk for falls related to difficulty walking with no support as evidence by not being able to see where she is walking, gripping on to furniture to find her way, having past injuries from falls.
Planning/Outcome Criteria
Chronic Pain a. Patient will have pain controlled by being monitored by a pain management specialist and prescribe medication that will alleviate pain but not cause narcotic like side effects. b. Patient will be given proper comfort measures to use such as a gel seat for when sitting on hard surface chairs and use of cushions and pillows when in bed. c. Head of bed will be elevated for comfort. Nursing aide will massage sore muscles and joints and use pain relieving creams such as Bengay. ("NANDA INTERNATIONAL," 2012)
Risk for Loneliness: a. Patient will demonstrate feelings of happiness and mental well-being. b. Patient will no longer have bouts of crying and depression. c. Patient will fell more independent and no longer as a burden. ("NANDA INTERNATIONAL," 2012)
Risk for falls: a. Patient will use walker when ambulating around the house b. Environment will be kept clear of clutter and rugs that may be tripped on c. Patient will be assisted to and from bathroom and when walking around the house. ("NANDA INTERNATIONAL," 2012)
Nursing Interventions
Chronic pain a. Provide opportunities for individuals to rest during the day and time of uninterrupted sleep at night. b. Talk with individuals and families use distraction therapy, along with other methods to reduce pain. c. Teach methods of distraction for acute pain, with regular breathing. d. Teach noninvasive pain reduction e. Give individuals the optimal reduction of pain with analgesics (Gulanick & Meyers, 2014).
Risk for Loneliness a. Active listening skills were used. Therapeutic relationship was established and time was spent with the patient on a regular basis. b. The client was encouraged to be involved in meaningful social relationships and personal attributes were supported. c. Ways to increase the client’s support system and participation in groups and organizations have been explored. d. Positive reinforcement was provided when the client sought out others (Gulanick & Meyers, 2014).
Risk for falls a. Assess home environment for threats to safety: clutter, slippery floors, scatter rugs, unsafe stairs and stairwells, blocked entries, dim lighting, extension cords b. Refer to physical therapy services for client and family education of safe transfers and ambulation and for strengthening exercises (for client) for ambulation and transfers c. Have client wear supportive low heeled shoes with good traction when ambulating d. Routinely assist client with toileting on his or her own schedule. Always take client to bathroom on awakening, before bedtime, and before administering sedatives e. Keep the path to the bathroom clear, label the bathroom, and leave the door open (Gulanick & Meyers, 2014)
Evaluation
Short term goals for the nursing interventions of chronic pain include reducing the amount of pain the patient suffers from by using temporary solutions such a analgesics, pain relieving creams, and using massage. The long term goal for relieving chronic pain would be to be treated by a pain management specialist to determine where the pain is originating and treat the problem from there. If one of the causes of pain is the type of chair or bed the patient is using, we can look into replacing them with more comfortable furniture. Short term goals for risk of loneliness are to talk with the patient and be as supportive as possible.
Give her someone to listen to her needs and try to make her feel better. This can be done by asking family for help and schedule people to visit regularly during the week. Long term goals for this nursing intervention would be that patient is no longer feeling hopeless and is not depressed. Short term goal for risk of falls would be that patient has a clear walkway to ambulate in her home. Also that she has the proper equipment such as a walker and her eyeglasses are the correct prescription. A long term goal would be that the patient is no longer at risk for falling and has someone to assist her at all times when walking so she does not fall. This patient is a very elderly woman and is need of a great deal of support and medical care. For her to achieve a healthy and happy lifestyle she does need these issues to be addressed. It is a lot of work for just one caregiver to manage on their own so family and nursing care should be resourced. Also proper medical care needs to be addressed to assure that her physical and mental needs are assessed and
treated.
References
Cherry, B., & Jacob, S. R. (2014). Contemporary Nursing (6th ed.). St. Louis, MO: Elsevier Mosby.
Gulanick, M., & Meyers, J. L. (2014). Nursing Care Plans Diagnoses, Inteventions, and Outcomes (8th ed.). Philadelphia, PA: Elsevier Mosby.
Nursing Diagnoses Definitions and Classifications 2012- 2014. (2012). In WILEY, & BLACKWELL (Eds.), Nursing Diagnoses . Ames, IA: Wiliey and Blackwell.
Melissa Wilcox
Grantham University
Transition to Pro Nursing
NUR402
Margaret McGannon
June 23, 2013
Nursing Process Paper
The family I will be assessing consists of four people living in the household. First is the grandmother who is 99 years old, her daughter who is 77 years old, and her son who is 50 years old and finally his son who is 17 years old. The grandmother of this family came to live in this household 6 years ago after she was unable to live by herself anymore. The mother of this house lived here with her husband until he passed away 4 years ago. Her son and grandson have always lived with them as well. He is a single dad and has raised his son alone for the past 10 years.
This is a Caucasian family living on a very limited fixed income. The …show more content…
grandmother receives her social security as income, the mother receives her social security as income and also her deceased husband’s pension, the son works sporadically as a maintenance man for the housing development they live in, and the grandson is in high school and does not work. They rent this apartment through a family member who charges them a reasonable monthly fee of $1000 for a three bedroom apartment. This family has lived here for over 30 years.
The 99 year old grandmother has many disabilities. She unable to walk short distances and is wheelchair bound. She is still able to walk to the bathroom from the kitchen but no further. She sleeps in the bedroom closest to the kitchen and the bathroom so the transferring is easier. She is legally blind and her sight is continually degenerating. Her hearing is also very poor and growing increasingly worse. She has been an insulin dependent type 2 diabetic for over 50 years. She is not very compliant with a diabetic diet or with checking her blood sugars regularly since she is unable to check it herself and does not prepare her meals for herself anymore. She depends on her daughter for mostly all her day to day needs. She needs assistance with filling her insulin syringes since she cannot see to measure the amount, but she is still able to administer the insulin herself in her abdomen. She has Congestive Heart Failure and is on many different medications. She has a pacemaker that was put in 6 years ago. She does regularly see her primary medical doctor once a month although it is getting very difficult for her to get to the appointments because she cannot walk very far at all. Even the short distances like to the bathroom make her very short of breath. She has had several gastrointestinal surgeries which affect her digestion and elimination process. She becomes constipated at times and uses an enema to assist in moving her bowels. She is overweight and has significant swelling in her lower extremities due to the CHF. Skin in dry but intact, she occasionally has a fungal rash under her abdomen under excess skin. She gets frequent urinary tract infections. She is continent but wears adult diapers for leakage or accidents. She receives home health care three times a week for a bed bath and light nursing care.
Her physical health is deteriorating significantly from her age and also her medical illnesses. Her mental health is still very much intact however she is very depressed and lonely most of the time. I think her stress level in high because she doesn’t want to feel like a burden to her daughter and her son. I think she feels unwanted there at times and that she also feels like she has nowhere else to go. There are no other family members that could take her in permanently due to work schedules and the ability to care for her.
She has no chemical substance abuse, in fact she is opposed to taking anything except Tylenol for pain which she has chronically. She suffers from severe arthritis pain in her neck, back, hips, and knees. She also complains of severe pain from hemorrhoids that are very large and cause pain when sitting. She refuses to take any form of narcotic or pain medicine because she doesn’t want to “get addicted”. She does not drink or smoke cigarettes.
Her daughter also has several health issues but is still very active and reasonably healthy. Her vision is manageable with glasses and her hearing is intact. She is also a type 2 diabetic but it is controlled with diet and medication. She takes blood pressure medication to manage her hypertension. She does not work and only drives very occasionally. She follows up with her doctor regularly. Her physical and mental statuses are well intact. Her stress level is very high at times due to the constant care she has to provide for her aging mother. At times she gets very frustrated being the sole caretaker of her 99 year old mother and lashes out in anger.
Her son living in the home has poor eyesight, no hearing in the left ear and also diabetic however he is not being treated by a physician or compliant with a diabetic diet. His education level is only 2 years of high school and does not have steady employment. He and his son rely on the income of his mother and grandmother to support them. His son is a teenager and is following in his father’s footsteps of being a poor student and lack of work ethic. He does not contribute to the family for income or help out around the house. There is questionable chemical substance abuse for him. He does not interact with the family and has a bad attitude most of the time.
To summarize, this family unit is dependent upon the elderly grandmother who is unable to care for herself anymore and her daughter who is under a great deal of stress from becoming the caretaker for her mother. There is little support from other family members. This is not because they don’t care or unwilling to help but because of their own busy lifestyles. The health risks for these two women are high but they are routinely getting medical checkups. Their medical coverage is through Medicare and most of their medical needs are met though this health care plan.
Nursing Diagnoses Statements
I will be concentrating on the grandmother of the household to create Nursing Diagnoses.
Physically, grandmother is 99 years old and suffers from severe arthritis and bone degeneration. She does not sit or sleep comfortably in her wooden kitchen chair or bed. 1. Chronic Pain related to severe arthritis and bone degeneration as evidenced by inability to move joints easily, difficulty walking, and trouble sitting or sleeping in one position.
Psychologically grandmother is depressed and has feelings of being alone and hopeless most of the time. She feels like a burden to her family for having to take care of her. 2. Risk for loneliness related to minimal family support and dependence on her daughter to be her caregiver. As evidence by bouts of depression and crying, feelings of sadness and hopelessness.
Safety issues have been a problem and continue to put her at risk. 3. Risk for falls related to difficulty walking with no support as evidence by not being able to see where she is walking, gripping on to furniture to find her way, having past injuries from falls.
Planning/Outcome Criteria
Chronic Pain a. Patient will have pain controlled by being monitored by a pain management specialist and prescribe medication that will alleviate pain but not cause narcotic like side effects. b. Patient will be given proper comfort measures to use such as a gel seat for when sitting on hard surface chairs and use of cushions and pillows when in bed. c. Head of bed will be elevated for comfort. Nursing aide will massage sore muscles and joints and use pain relieving creams such as Bengay. ("NANDA INTERNATIONAL," 2012)
Risk for Loneliness: a. Patient will demonstrate feelings of happiness and mental well-being. b. Patient will no longer have bouts of crying and depression. c. Patient will fell more independent and no longer as a burden. ("NANDA INTERNATIONAL," 2012)
Risk for falls: a. Patient will use walker when ambulating around the house b. Environment will be kept clear of clutter and rugs that may be tripped on c. Patient will be assisted to and from bathroom and when walking around the house. ("NANDA INTERNATIONAL," 2012)
Nursing Interventions
Chronic pain a. Provide opportunities for individuals to rest during the day and time of uninterrupted sleep at night. b. Talk with individuals and families use distraction therapy, along with other methods to reduce pain. c. Teach methods of distraction for acute pain, with regular breathing. d. Teach noninvasive pain reduction e. Give individuals the optimal reduction of pain with analgesics (Gulanick & Meyers, 2014).
Risk for Loneliness a. Active listening skills were used. Therapeutic relationship was established and time was spent with the patient on a regular basis. b. The client was encouraged to be involved in meaningful social relationships and personal attributes were supported. c. Ways to increase the client’s support system and participation in groups and organizations have been explored. d. Positive reinforcement was provided when the client sought out others (Gulanick & Meyers, 2014).
Risk for falls a. Assess home environment for threats to safety: clutter, slippery floors, scatter rugs, unsafe stairs and stairwells, blocked entries, dim lighting, extension cords b. Refer to physical therapy services for client and family education of safe transfers and ambulation and for strengthening exercises (for client) for ambulation and transfers c. Have client wear supportive low heeled shoes with good traction when ambulating d. Routinely assist client with toileting on his or her own schedule. Always take client to bathroom on awakening, before bedtime, and before administering sedatives e. Keep the path to the bathroom clear, label the bathroom, and leave the door open (Gulanick & Meyers, 2014)
Evaluation
Short term goals for the nursing interventions of chronic pain include reducing the amount of pain the patient suffers from by using temporary solutions such a analgesics, pain relieving creams, and using massage. The long term goal for relieving chronic pain would be to be treated by a pain management specialist to determine where the pain is originating and treat the problem from there. If one of the causes of pain is the type of chair or bed the patient is using, we can look into replacing them with more comfortable furniture. Short term goals for risk of loneliness are to talk with the patient and be as supportive as possible.
Give her someone to listen to her needs and try to make her feel better. This can be done by asking family for help and schedule people to visit regularly during the week. Long term goals for this nursing intervention would be that patient is no longer feeling hopeless and is not depressed. Short term goal for risk of falls would be that patient has a clear walkway to ambulate in her home. Also that she has the proper equipment such as a walker and her eyeglasses are the correct prescription. A long term goal would be that the patient is no longer at risk for falling and has someone to assist her at all times when walking so she does not fall. This patient is a very elderly woman and is need of a great deal of support and medical care. For her to achieve a healthy and happy lifestyle she does need these issues to be addressed. It is a lot of work for just one caregiver to manage on their own so family and nursing care should be resourced. Also proper medical care needs to be addressed to assure that her physical and mental needs are assessed and
treated.
References
Cherry, B., & Jacob, S. R. (2014). Contemporary Nursing (6th ed.). St. Louis, MO: Elsevier Mosby.
Gulanick, M., & Meyers, J. L. (2014). Nursing Care Plans Diagnoses, Inteventions, and Outcomes (8th ed.). Philadelphia, PA: Elsevier Mosby.
Nursing Diagnoses Definitions and Classifications 2012- 2014. (2012). In WILEY, & BLACKWELL (Eds.), Nursing Diagnoses . Ames, IA: Wiliey and Blackwell.