Question

Scenario

George Miller, a 68-year-old man who had a stroke 6 months ago, comes to the urgent care clinic complaining of abdominal pain and nausea. Mr. Miller lives alone in an assisted living complex. He was never married, and his only relative is a 70-year-old sister who visits him two to three times a week. Miller uses a quad cane to ambulate because of hemiplegia on his left side and eats his meals in the central dining room at the complex. The complex has no licensed health care workers.

You are the nurse assigned to the urgent care clinic and are assigned to care for the patient. You perform your initial assessment on Mr. Miller and while you are obtaining his history, Mr. Miller tells you that he has not had a bowel movement in 4 days. On physical examination, Mr. Miller’s abdomen is hard, and he has hypoactive bowel sounds in all four quadrants. He states he is experiencing abdominal pain in right and left lower quadrants and rates the pain as 8/10 on a scale of 0-10. You obtain the following vital signs: BP- 100/60, HR- 110, respirations 20/min, temperature 98.4, pulse oximeter of 94% on room air (RA). The physician determines that Mr. Miller has constipation and has a fecal impaction.

ASSESSMENT

Identify and include at least 3-5 significant subjective symptoms by underlining and highlighting them in the scenario above and then list them below.

Identify and include at least 3-5 objective assessment symptoms by underlining and highlighting them in the scenario above and then list them below.

DIAGNOSIS

Select at least 3-5 possible NANDA nursing diagnoses appropriate NANDA nursing diagnoses for this client and list them below.

Write 3 nursing diagnostic statements for this patient’s major problems and write the nursing diagnostic statements accordingly with use of a three-part nursing diagnosis: Problem + etiology as evidenced by signs and symptoms. (Example would be: Acute pain r/t injury as evidenced by verbalization of back pain of 5/10 on a scale of 0-10.)

Nursing diagnosis #1-

Nursing diagnosis #2-

Nursing diagnosis #3-

PLAN

Write one short-term outcome and one long-term goal for each of your 3 nursing diagnoses above. Remember SMART goals.

Nursing diagnosis #1-

Short-term goal:

Long-term goal:

Nursing diagnosis #2-

Short-term goal:

Long-term goal:

Nursing diagnosis #3-

Short-term goal:

Long-term goal:

IMPLEMENTATION

As the patient’s nurse, include 3 other nursing interventions with rationales that you would facilitate for each of your 3 nursing diagnoses to help the patient meet their specific goals. This could include use of referrals, delegation and use of an interdisciplinary team.

Nursing diagnosis #1-

1)

2)

3)

Nursing diagnosis #2-

1)

2)

3)

Nursing diagnosis #3-

1)

2)

3)

EVALUATION

For each 3 nursing diagnoses chosen above, answer the following question below. Be specific with your answers.

How would evaluate that your goals that you selected were specific to the patient’s condition and situation?

Nursing diagnosis #1-

Nursing diagnosis #2-

Nursing diagnosis #3-

Answer 1

1. Severe abdominal pain related to decreased bowel movements as evidenced by verbalization of abdominal pain of 8/10 on the scale of 0-10.

Assessment	Dignosis	Goal	Implimentation	Evaluation
Subjective data THe patient has verbalized that he is having the abdominal pain since 4-5 days. Objective data The patient is having severe abdominal pain as evidenced by 8/10 on the scale of 0/10 Painfull facial expression Looks weak	Severe abdominal pain related to decreased bowel movements as evidenced by the verbalization of abdominal pain of 8/10 on the scale of 0-10	Short term goal After 30 minutes of nursing interventions the patients abdominal pain will decrease from 8/10 to 2/10 or lower. Long term goal After one week of care the patient's abdominal pain will be completely resolved or controlled.	1) Assess the base line data about the location,sevearity and charactor of pain. 2) Provide compfortable position to the patient 3) Assess for the portable cause of pain 4)Administer the analgesics as per the docto'rs order.	Goal met. After 3 hours of the nursing care the patient verbalized relief of pain and rated it as 2/10 from 8/10 in pain scale

2. Constipation related to decreased bowel movements as evidenced by verbalization of no bowel movements in 4 days.

Assessment	Diagnosis	Goal	Implimentation	Evaluation
Subjective data The patient has been verbalized that he is not having adequate bowel movements in past 4 days and he looks very tired. Objective data Hypoactive bowel sounds in four quadrants. Paient looks tired and weak	Constipation related to decreased bowel movements as evidenced by verbalization of no bowel movements in 4 days.	Short term goal After 30 minutes of nursing care the patient's constipation will be reduced Long term goal After 5 days of nursing interventions the patients constipation will be completely resolves and he will be back to the early state.	1) Advice the patient to take high fiber rich foods 2) Provide enema as per physician's order 3) Adminiater laxatives as per the doctors order.	Goal met After 30 minutes of nursing interventions the patients constipation has been relived with a normal bowel sound

3. Ineffective breathing pattern related to hypotension as evidenced by decreased respitatory rate.

Assessment	Diagnosis	Goal	Implmentation	Evaluation
Subjective data The patient has been complaints about nausea and breathing difficulty. Objective data Vital signs taken as follows Temprature :- 98.4 degree celcious Pulse :- 110 beats/min Respiration :- 20 breaths/min BP :- 100/60 mm of Hg	Ineffective breathing pattern related to hypotention as evidenced by decreased respiratory rate	Short term goal After 30 minutes of nusring interventions the patient will de relieved from the breathing difficulty. Long term goal After one week of nursing intervention the patient patient will be relieved from the breathing diffculty and back to the early life.	1) Check the vital signs of the patient 2) Provide nebulization 3) Administer broncho dialaters as per the doctors order.	Goal met After 30 minutes of nuring care the patient's breathing difficulty has been relived as edidenced by the vital sign monitoring