Nursing Process Lab Final

7/24/2019 Nursing Process Lab Final

1/8

Nursing Process / Laboratory

Case Study

Example 1:

Sinusitisis inflammation of the paranasal sinuses, which may be due to infection,

allergy, or autoimmune issues. Most cases are due to a viral infection and resolve

over the course of 10 days. It is a common condition; for example, in the United

tates more than !" million cases occur annually.

Nursing Diagnosis for Sinusitis

1Acute Pain# head, throat, sinus related to inflammation of the nose

$oal # %ain is reduced or lost

&xpected outcomes are#

'lients express the pain diminished or disappeared

'lients do not grimace in pain

Interventions:

1. (ssess client)s level of pain

* #+ nowing the client)s level of pain in determining further action

!. &xplain the causes and effects of pain on the client and family

* #+ -ith the causes and conseuences of pain the client is expected to participate in

treatment to reduce pain

/. each relaxation techniues and distractions

* #+ he client nows the distraction and relaxation techniues can be practiced so as

if in pain

". 2bservation of vital signs and client complaints

* #+ nowing the general state and development of the client)s condition.

!.Anxietyrelated to lac of client nowledge about diseases and medical procedures


2/8

3sinus irrigation + operation4

$oal# (nxiety is reduced + lost

&xpected outcomes are# 'lients will describe the level of anxiety and coping patterns.

he client nows and understands about his illness and its treatment.

Interventions:

1. (ssess client)s level of anxiety

* #+ 5etermining the next action

!. $ive comfort and etentaman on the client# how empathy 3it comes with a touch client4

* #+ 6acilitate client)s receipt of the information provided

/. $ive an explanation to clients about the illness slowly, uietly and use of clear

sentences, short easy to understand

* #+ Increase client understanding about the disease and therapies for the disease so

that the client more cooperative

". $et rid of excessive stimulation such as#

%lace the room uieter client

7imit contact with others + other clients are liely to experience anxiety

* #+ 8y removing the stimulus that will enhance the peace of the client concerned.

/.Ineffective Airway Clearancerelated to the obstruction 3nasal secret buildup4

secondary to inflammation of the sinuses

$oal# &ffective airway, after a secret 3seous, purulent4 issued

&xpected outcomes are#

'lients no longer breathe through the mouth

(irway bac to normal, especially the nose

Interventions:

1. (ssess the existing build9secret


3/8

* #+ nowing the severity and subseuent action

!. 2bservation of vital signs

* #+ nowing the client)s development prior to surgery

/. 'ollaboration with the medical team for cleaning discharge

* #+ cooperation to eliminate the buildup of secret + problem

Example!#

Risk for Injury of Hemophilia

Nursing Diagnosis : Risk for Injuryrelated to weakness of the defense secondaryto hemophilia

characterized by frequent injuries

Objectives / Expected outcomes: injury and complications can be avoided / did not

happen.

ursin! "nterventions

#. $aintain security of client%s bed& put a safety on the bed

'. (void injury& li!ht ) wei!ht

*. +eep an eye on every move that allows the occurrence of injury

,. Encoura!e the parents to brin! children to the hospital immediately in case ofinjury

-. Explain to parents the importance of avoidin! injury.

ational

#. ra!ile tissue and impaired clottin! mechanisms boost the risk of bleedin!despite the injury / mild trauma

'. 0atients with hemophilia are at risk of spontaneous bleedin! was controlled sothat the required monitorin! every move that allows the occurrence of injury

*. Early identification and treatment can limit the severity of complications

,. 0arents can find out mamfaat of injury prevention / risk of bleedin! and avoidinjury and complications.

-. 1ower the risk of injury / trauma.


4/8

Example3:

Constipation / Diarrhea related to Anemia

Nursing Diagnosis: Constipation / Diarrhea related to a reduction in dietary

inputs& chan!es in di!estion& the side effects of oral therapy.

2i!ns :

frequency chan!e characteristics and the amount of feces

nausea / vomitin!

anorexia

sudden abdominal pain

impaired bowel sounds.

Expected outcomes are:

normal bowel function

behavioral chan!es necessary to live as the cause.

ursin! "ntervention:

Observation of color& consistency& frequency& amount. (uscultation of bowel sounds

2upervise the input/ output

Encoura!e input '-33)*333 ml

4onsult with a nutritionist: hi!h)fiber diet

5ive an enema as indicated

5ive anti)diarrheal medications as indicated.


5/8

Example4:

ppendicitisis nown to be a surgical disease, as it commonly reuires

removal of the inflamed vermiform appendix, a tubular prominence of the

cecum.

'auses of acute appendicitis#

he appendix contains a lumen in it. (nything that causes obstruction of the

lumen will cause appendicitis. In adults, the lumen is commonly obstructed by

fecaliths. 6ecalith means hard fecal matter.

In teens and children, the lumen can be obstructed due to inflammation

3submucosal lymphoid hyperplasia4.

(ppendicitis symptoms present itself as a type of acute abdominal pain. It

usually spreads around the person)s abdomen)s lower right region. (fter some

time, the infection spreads and the intensity of pain will increase. :ou can

distinguish the pain because it seems sharper as compared to other typical

abdominal conditions.

omiting and anorexia can occur after the feeling of pain. 8esides, an elevated

body temperature is a sign of an ongoing inflammation in the body.

Nursing Diagnosis

1. *is for Infection

!. (cute pain

/. *is for 6luid olume

". (nxiety


6/8

Exam: (sthma is a very serious condition so everyone should be aware of the

symptoms. (sthma is a common respiratory disease that affects a person)s

airways. (sthma affects the individual)s ability to breathe normally and can

cause tightness in the chest, coughing and whee=ing and shortness of breath, in

more serious cases it can trigger asthma attacs that can be life threatening to

the individual.

Numerate t!e Nursing Diagnosis for st!ma


7/8

Exam

Dengue "e#er

5engue fever is an acute febrile disease caused by dengue virus and

is spread through the medium of the (edes aegypti mosuito, which had

been infected with the dengue virus. 5engue fever is divided into two,

namely# dengue fever and dengue hemorrhagic fever. 5engue hemorrhagic

fever is a more severe form of dengue fever, bleeding and shoc, which

can sometimes occur that result in death.

$!at are t!e Nursing Diagnosis:


8/8

Exam

uberculosis is a common and very dangerous as well as a contagious

disease which can be caused by a range of strains of mycobacteria % he bacteriacausing tuberculosis can be spread from one person to the next via particles in the air

he important symptoms of uberculosis are chest pain, coughing up blood, and a

productive and lingering cough for more than three wees. here are some of the

systematic symptoms of this disease too and these are continuous fever, chills,

freuently getting night sweats, immediate appetite loss, weight loss, whiteness, and

feeling exhausted in most of the time. he infected person has odorous mucus. ome

of the extra pulmonary infections can be included, lie the pleura in tuberculosis

pleurisy for which the central nervous system gets affected.

$!at are t!e Nursing Diagnosis

Documents

Nursing Process Lab Final