Question

Read the case scenario and apply the FIVE STEPS OF THE NURSING PROCESS.

Identify:

-Three appropriate nursing diagnoses

-For each nursing diagnosis provide one goal/expected outcome (goal should be SMART)

-Three nursing interventions for each diagnosis (independent, dependent, collaborative) and with scientific rationale

-One evaluative statement for each nursing diagnosis (indicate if goal met, goal partially met, or goal not met)

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Follow the standard format of a nursing care plan. Thank you.

Levi Yosh is a 36-y/o police officer assigned to a high crime police precinct. One week ago he received a surface bullet wound to his arm. Today he arrives at the outpatient clinic to have the wound redressed. While speaking with the nurse, Mr. Yosh mentions that he has been promoted to the rank of detective and has assumed new responsibilities. He states that since his promotion, he has experienced increasing difficulty falling asleep and sometimes staying asleep. He expresses concern over the danger of his occupation and his desire to do well in his new position. He complains of waking up feeling tired and irritable. During the interview the nurse notes that he is pale, drawn with dark circles under his eyes. Temp: 37.0 C Pulse: 80 bpm, Resp: 18cpm, BP: 140/90mmHg

Answer 1

1)Nursing diagnosis

Distrubed sleep pattern related to new responsibilities in job as a result of promotion as evidenced by verbal complaints of falling asleep and dark circles around his eyes.

Expected outcome :achieves optimal amountbof sleep as evidenced by verbalization.

Nursing intervention and rationale:

i)Assess patients perception of cause of sleep difficulty and possible relief measures to facilitate treatment.- Knowing the specific etiological factor leads to proper therapy.

ii)Explain the need to avoid concentrating on the next day activities or problems at bedtime - this will interfere with inducing a restfull state.

iii)provide nursing aids such as back rub, pain relief,comfortable position teqniques- To promote rest.

Evaluation :Feels fresh on getting up and reduced darkness around eyes.

2)Nursing diagnosis

Anxity related to threat to self concept as evidence by increase in blood pressure(140 mmHg).

Expected outcome: Demonstrate positive coping mechanism.

Nursing intervention - Rationale:

i)Reassure patient that he is safe - The presence of a trusted person may be helpful during anxiety say a security .

ii)Assist the patient in developing anxiety reducing skills (rekaxatiin deep breathing,positive visualization ) - using anxiety reduction ploys enchances patients sense of personal mastery and confidence.

iii)Establish a working relationship with the patient through continuity of care - An ongoing relationships can give a comfort in communicating anxious feelings.

Evaluation: The patient has less misperception over new resposibilities.

3)Nursing diagnosis.

3)Activity intolerance related to insufficient sleep as evidenced by verbal report of fatigue.

Expected outcome: The patient will identify factors that reduce activity tolerance.

Nursing intervention - Rationale

i)Determine patients perception of causes of fatigue - Assessment guides treatment.

ii)Asses nutritional status - adequate energy reserves are required for activity.

iii)Teach appropriate use of environmental aids such as bedrails - To conserve energyand orevent injury from fall.

Evaluation: The patient is less irritable and perform activities.