Nursing Theorist

University of Phoenix Material
Name: Veronica Diaz Date:04/21/2014
Case Study Grid

List 5 factors of the patient’s history that demonstrate nursing needs.

Complete the table below with the following information:

Formulate 3 nursing diagnoses using the Problem, Etiology, and Signs and Symptoms (PES) format and the taxonomy of NANDA. The diagnoses must be based on the case study, be appropriate, be prioritized, and be formatted correctly.

For each nursing diagnosis, state 2 desired outcomes using NOC criteria. Desired outcomes must be patient-centered and measurable within an identified timeframe.

For each outcome, state 2 nursing interventions using NIC criteria as well as 1 evaluation method. Interventions and the evaluation method must be appropriate to the desired outcomes.

Provide rationale for each nursing diagnosis, and explain how PES, NANDA, NOC, and NIC apply to each diagnosis.

Use a minimum of 3 peer-reviewed resources, and create an APA formatted reference page.

Nursing Diagnosis 1: Urinary Retention R/T Anesthesia

Nursing Interventions
Desired Outcome 1

Desired Outcome 2
Nursing Intervention Visually inspect and palpate lower abdomen for distention (Mosby 2012).

Patient’s abdominal girth will not increase and distention will decrease. Patient will remain free of abdominal pain r/t urinary retention.
Nursing Intervention 2 Urinary Catheterization (Mosby 2012)
Patient will empty bladder >30ml an hour
Patient will demonstrate clean technique if performing self-catheterization.
Evaluation method

Measure input and output hourly to obtain accurate measurements.
Make sure catheter is free of kinks to allow for proper drainage
Rationale

Keeping accurate records of I/O will ensure that the patient is evacuating properly.
Ensuring patient is free of pain will promote less anxiety and keep vital signs within range. Educating patient on clean technique will promote an environment with less bacteria and keep risk of infection lower.

Nursing Diagnosis 2: Risk for Infection/RT Urinary Catheter

Desired Outcome 1
Desired Outcome 2
Nursing Intervention 1 Infection Control

Patient remains free of infection, as evidenced by normal vital signs, and absence of purulent drainage from wounds, incisions, and tubes (Mosby 2012).
Infection is recognized early to allow for prompt treatment (Mosby 2012).
Nursing Intervention 2 Infection Protection

Teach patient to wash hands often, especially after toileting, before meals, and before and after administering self-care (Mosby 2012).
Teach patient importance of eating well balanced meals to promote healthy nutritional status.
Evaluation method

Evaluate patient perform self-care as to promote further education.
Allow patient to verbalize and demonstrate understanding of proper nutrition and signs of infection.
Rationale

Patients with indwelling catheters need to be shown clean techniques when being discharged home. Educating patient on proper hand washing will promote clean environment and keep patients risk of infection lower.
Educating patient on the early signs of infection will promote prompt medical intervention. Educating patient on proper nutrition and importance of well balanced meals will promote faster healing of incision and lower patients’ risk of infection.

Nursing Diagnosis 3: Pain R/T Postoperative pain

Desired Outcome 1
Desired Outcome 2
Nursing Intervention 1
Anticipate need for pain relief (Mosby 2012)

Anticipating pain may result in medicating at a lower dose to keep patient comfortable.
Maintaining a level of comfort where the patient is not begging for relief. Keeping vital signs stable while maintaining the patient comfortable.
Nursing Intervention 2
Respond immediately to complaint of pain (Mosby 2011)

Creates a trusting relationship with patient to ensure open lines of communication.
Allows the patient to know that you are empathetic to their discomfort and that they are not alone.
Evaluation method

Evaluate scheduled times of medication administration. Round hourly on the patient as to reassure the patient that their needs will be met.
Educate patient on medication administration time so they are not waiting until their pain is at a level 8 before they ask for relief. Evaluate the responses from the patient as to ensure that they are feeling comfortable with the care.
Rationale

Anticipating pain will allow the nurse to be on time for the patient in pain. Creating that trusting relationship with the patient will allow open lines of communication with the patient which will in turn allow for better care and outcome.
Educating a patient on when to ask for medication will ensure that the patient never reaches a level of extreme pain. Treating your patient with compassion and empathy will allow for the patient to feel satisfied with the care they are receiving and create a trusting relationship.

Reference

Swearingen, P. L. (2012). All-in-one care planning resource: medical-surgical, pediatric,

maternity, psychiatric nursing care plans (3rd ed.). Philadelphia, PA:

Elsevier/Mosby.

Gulanick, M. (2011). Nursing care plans: diagnoses, interventions, and outcomes (7th

ed.). St. Louis, Mo.: Elsevier Mosby.

Doenges, M. E., & Moorhouse, M. F. (2002). Nursing care plans guidelines for

individualizing patient care (6th ed.). Philadelphia: F.A. Davis.