Situation: Dolores Wellbeing, a 35 yr old sales lady, reports weakness, and flu

Situation: Dolores Wellbeing, a 35 yr old sales lady, reports weakness, and flu-like symptoms for 3-4 days. Although thirsty, she is unable to tolerate fluids because of nausea and vomiting, and she has liquid stools 2-4 times per day.Physical ExaminationHt: 5’3Wt: 166lbsTemp: 38.6PR: 86BPMRR: 24CPMBP: 130/90Diagnostic DataUrine specific gravity: 1.0357Serum Sodium: 155meq/ LCXR: negative Formulate a Nursing Care Plan based on this situation. Give rationale to every intervention. You can use NANDA as your guide in formulating.  USE THE SAMPLE FORMAT BELOWNURSING CARE PLAN SAMPLEMR. BOWICK HAS HAD A SUCCESSFUL REPAIR OF A FRACTURED HIP AND IS RECOVERING, WITH A PROBLEM OF ACUTE PAIN. HE IS WAITING FOR DISCHARGE AND NEEDS CLIENT EDUCATION IN THIS REGARD. MR. BOWICK WILL NEED DIRECTION AS TO WHETHER HE IS ABLE TO GO HOME WITH HOME HEALTH NURSING SUPERVISION AND ASSISTANCE OR IF HE WILL NEED TO BE ADMITTED TO A CONVALESCENT SETTING.  ASSESSMENTNURSING DIAGNOSISEXPECTED OUTCOMEPLANNING/INTERVENTIONRATIONALEEVALUATIONSUBJECTIVE SYMPTOMACUTE PAIN ACUTE PAIN RELATED TO RECENT REPAIR OF THE FRACTURED LEFT HIP NOC (NURSING OUTCOME CLASSIFICATION): PAIN LEVEL, PAIN CONTROL, COMFORT LEVEL, PAIN; DISRUPTIVE EFFECTNIC (NURSING INTERVENTION CLASSIFICATION)PAIN MANAGEMENT, ANALGESIS ADMINISTRATION, PATIENT – CONTROLLED ANALGESIATHE CLIENT WILL:STATE HE HAS DECREASED LEVEL OF PAIN (SCALE OF 1-10) WITHIN 48 HOURSVERBALIZE SUCCESSFUL MEASURES THAT IMPROVE HIS COMFORT LEVEL BEFORE DISCHARGECOLLABORATE WITH CLIENT IN DETERMINING WHAT METHODS CAN BE USED TO REDUCE THE PAIN LEVELPREDICATE THE CLIENT 30 -60 MINUTES PRIOR TO AMBULATINGINCREASES THE SELF-EFFICACY OF THE CLIENT IN PAIN RELIEF METHODS.PREVENT PAIN LEVELS FROM INCREASING BEYOND THE PAIN THRESHOLD. THE CLIENT STATES THAT HIS PAIN LEVEL HAS DECREASED FROM   6-3 ON THE PAIN MANAGEMENT SCALE OF 1-10 AND HE IS ABLE TP AMBULATE WITH LESS DISCOMFORT. INEFFECTIVE HEALTH MAINTENANCE FROM RECENT SURGERY, ASA RELATED TO IMPENDING DISCHARGE.NOC; HEALTH BELIEFS, PERCEIVED RESOURCES; HEALTH-PROMOTING BEHAVIOR, HEALTH SEEKING BEHAVIOR NIC; HEALTH SYSTEM GUIDANCE, SUPPORT SYSTEM ENHANCEMENT, HEALTH EDUCATIONTHE CLIENT WILL:IDENTIFY THE BARRIERS IN HEALTH MAINTENANCE IN WHICHEVER ENVIRONMENT HE IS DISCHARGED TO WITHIN 3 DAYS OF RELOCATINGENGAGE IN HEALTH MAINTENANCE BEHAVIORS, SUCH AS PERSONAL HYGIENE, WITHIN 3 DAYS OR RELOCATING   THE CLIENT WILL ASSESS BARRIERS TO HEALTH MAINTENANCE      ASSIST THE CLIENT IN IDENTIFYING HEALTH BEHAVIORS THAT ARE COMPATIBLE WITH HIS LIFESTYLE AFTER THE SURGICAL REPAIR OF THE LEFT HIP  ENCOURAGE PATIENT TO DISCOVER METHODS OF IMPROVING HIS STATE OF HEALTH   ALLOWS REALISTIC PLAN FOR THE CLIENT TO ADAPT TO HIS LIMITATIONS CREATED FROM THE RECENT SURGERY       THE CLIENT IDENTIFIED THE HEALTH BARRIERS OF HIS RECENT SURGERY AND DEVELOPED A PLAN FOR OVERCOMING THE DEFICIENCIES Health Science Science Nursing NCMA 111 Share EmailCopy link Comments (0)

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