Question

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

Identify:

-Three appropriate nursing diagnoses (Problem related to Etiology as manifested by Signs and Symptoms, problem related to Etiology, problem)

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

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

-One evaluative statement (goal met, goal partially met, goal not met)

Follow the standard format of a nursing care plan.

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 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

?Assessment: subjective data the patient says that he is having difficulty in falling asleep and stay asleep
:Objective data
Verbalization, dark circles around the eyes paleness increased BP pulse and respiration

?Diagnosis
insomnia and sleep inertia related to anxiety as evidenced by dark circles around the eyes and patient verbalization
Decreased the blood circulation related to anxiety as evidenced by paleness.

?Goal. : patient maintain normal activity

?Planning
Assess the general condition of the patient

Provide a comfortable atmosphere for the patient to fall asleep

Avoiding caffeine alcohol or any other sleep disturbing actions before few hours for sleep

Providing a healthy sleep with pattern

Administer sleeping pills as per physician order

?Rational
To get a baseline data

To make the patient comfortable

To reduce sleep disturbances

To make a regular sleeping pattern

To promote sleeping

?Implementation
Assess the general conditions of the patient

Provide comfortable atmosphere free from noise and light for the patient

restricted the use of caffeine alcohol and other sleep disturbing agents before few hours for sleep

Provided healthy sleep wake pattern

Administered sleeping pills.