Question

Apply the nursing Process to the following

Hypothetical situation

just answer question 6,7

Mrs. Rojas, 30 years old, came to the emergency room with a cold two weeks ago, she presented dyspnea (difficulty breathing). It indicates that you have a fever, headache for several days, chest pain, and you have to sit up to breathe well. Also, complaints of chills have decreased fluid intake 2 days ago. On physical examination temp. 39.5C, pulse 92 reg., Strong, Resp. 22 / min. Superficial. B / P 122/80., Dry mouth mucosa, pale, hot skin, reddened cheeks. Decreased vesicular and crackling sounds on inspiration in the right upper and lower lobe. Its thoracic expansion is 3 cm., Scant cough, dense sputum of light pink color. Lethargic, weak, and fatigued appearance. The doctor suspects that this may have the diagnosis Influenza A H1N1.
After reading the situation, answer the following questions;
1.After reading and analyzing the situation, identify the estimated data, and classify them as subjective and objective.

2. Mention the problems that you infer in this situation?

3. According to the NANDA category, which nursing diagnosis applies in this situation. (It must include Problem, etiology and symptoms).

4. Develop the expected result for this Situation

5.Develop nursing interventions such as coordinating and managing
Care of this patient, include the nursing orders and justification for each intervention. (Complete the table).

                   Nursing orders                                    Justification                              

6. Mention what legal ethical implications should be considered in this condition.

7. List and define the six nursing steps and define them.

Answer 1

Ans:

6). Legal ethical implications should be considered in this case-

- The rapid spread of the influenza A H1N1 swine flue origin leads to widespread fear, panic and unrest among the public and healthcare personnel.

- The pandemic not only tested the world health preparedness, but also brought up new ethical issues which need to identify as soon as possible.

- The main areas that require attention are the distribution of scares resources, prioritisation of antiviral drugs and vaccination, obligations of healthcare workers and adequate dissemination and proper communication of information related to the pandemic.

- It is great importance to plan in the advance , how to confront these issues in an ethical manner.

- The main implications of influenza is lost of work time and reduced productivity of patients and caregivers and increased use of medical resources.

- The rate of morbidity and mortality increased.

- The economic status of affected community or country became down.

7). Nursing steps- ( ADOPIE)

1. Assessment

2. Diagnosis

3. Outcome identification-

4. Planning

6. Implementation

7. Evaluation.

Defination:

1. Assessment-

Assessment is the first step of nursing process and involves critical thinking skills and data collection in form of subjective and objective data. Subjective data involves verbal statement from the patients or caregiver. Objective data is measurable, tangible and output, and height and weight.

2. Diagnosis-

A nursing diagnosis is defined as " a clinical judgment about an individual, family or community responses to actual and potential health problems . Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

3. Outcome identification-

The expected outcome qualifiers represent the goal of the patient care and are documented in the future tense as: will improve, will stabilize, will deteriorate , whereas the actual outcome qualifiers represent whether the goals were met or not met and are documented in the past tense as: improved.

4. Planning-

Planning is a deliberative, systematic phase of the nursing process that involves, decision making and problem solving.

5. Implementation-

Implementation provide the actual nursing activities and client response. It consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders.

6. Evaluation-

It is defined as the judgement of the effectiveness of nursing care to meet client goals; in this phase nurse compare the client behavioural responses with predetermined client goals and outcome criteria.