Question

You are a nurse admitting a patient to

the hospital from the emergency

department with severe abdominal pain

of unknown origin. He is a 42-year-old

construction worker who has a history

of asthma and sleep apnea. He is

accompanied to the hospital by his

wife, and they have four teenage

children who live at home. His wife is an

elementary school teacher. The

physician has written orders, which

includes several tests.

1.What data in the scenario is

pertinent? (This is part of the

assessment.)

2. What are the patient's strengths,

actual and/or potential problems?

(This is developing the nursing

diagnosis.)

3. What would you consider as

desired goals? (This is planning

your anticipated nursing care.)

4. What holistic contributions would

you make to reach these goals?

(This would be the

implementation of the planned

nursing care.)

5.What would be your next step?

Answer 1

1 what data in the senario is pretinant:

(a) Detailed assessment which include : (this is part of the assessment)

• History collection : Ask the patient history which include family history in the family anybody is having the disease like astha and sleep apnea or any other disease condition is there means how many years and did they take any medicine, patient medical history, surgical history, findout any allergies, food habits
• Physical examination: head toe examination. especially the patient having abdominal pain so do abdominal palpation, inspection, percussion and auscultaion and also do his respiratory assessment2
• Laboratory examination

2. what are the patients strengths actual or pottantial problems? (this is developing the nursing diagnosis

In the history collection, physical examination and laboratory examination we can find out the patient problems based on this problems first w can priortise the problem and diagnose the problems

NURSING DIAGNOSIS

(a) abdominal pain:

• Acute pain related to abdominal irritanse as evidanced by pain scre

(b) Symptoms of asthma patients: shortness of breath, trouble sleeping and cough

• Ineffective breathing pattern related to cough as evidenced by shortness of birth
• Impaired gas exchange related to collection of mucus in the airways as evidenced by excessive secretion

(c) sleep apnea

• disturbed sleeping pattern related to shortness of birth as evidenced by drowsy eys

(d) common problems are: fatigue, anorexia, weakness, nousia and vomkting and knowledge deficit

• fluid volium deficit related to vomiting as evidenced by poor skin turgor
• fatigue related to disease condition as evidenced by facial expression
• activity intolerance related to muscle weakness
• knowledge deficit related to disease conditin as evidenced by asking questions

3. What would you consider as desired goals? (This is planning your anticipated nursing care.)

(a) goals are:

• The patient pain will get reduced
• The patient maintain normal breathing patten
• To maintain normal sleeping pattern
• Patient maintain normal fluid volium
• To reduce the fatigue
• To maintain normal daily living activities
• The paitien will have adequete knowledge regarding the treatment process and his condition

(b) Anticipated nursing care ;

• Assess the condition of the patient
• Check the pain score
• Check the vital signs
• Administre medication as per doctors order especially pain relif medicine,
• Educate the patient regarding the disease condition
• Check the btething pattern
• Educate the patient regarding breathing excirse
• Adminstre oxygen
• Administre nebulization
• Asisst the patient daily living activities
• Adminstre IV fluids
• Advise the patient to drink more water
• Provide psychological support

4. What holistic contributions wouldyou make to reach these goals?(This would be the implementation of the planned nursing care.)

Holistic contribution is consider the physical, emtional social economic and spritual needs of the person, his or her response to illness and the effect of the illness on the ability to meet self care needs

(a) Implimentaion:

• Assessed the condition of the patient
• Checked the pain score
• Checked the vital signs such as temperature, pulse, respiration, and BP
• Administred medication as per doctors order especially analgecic , example diclofinac,
• Thought the patient regarding the disease condition such as asthma, sleep apnea and abdominal pain
• Checked the btething pattern
• Thought the patient regarding breathing excirse likes deep breathing excirse
• Adminstred oxygen as per doctors order
• Administred nebulization such as asthalin, salbutamol
• Assissted the patient daily living activities
• Adminstred IV fluids likes DNS, NS
• Advised the patient to drink more water which include plain water, juice
• Provide psychological support

5. What would be your next step?

(a) Evaluation: evaluating the planned, ongoing purposeful activity in which the patient progress towards the achievement of goals or disired outcomes and the effectiveness of nursing care and also to determine whether to continue, modify or terminate the plan of care