Vanessa Rene Griggs
About Me: Nursing Process
The nursing process includes: Analysis, Evaluation, Assessment, Nursing Diagnosis, Planning, and Implementation.
She was also noted to have an open wound on her right lower leg, per patient it occurred last week when she fell in her bathroom. Wound with purulent drainage and redness.
On routine tests patient results came to show dehydration. Her blood sugar was elevated at 400 and also was diagnosed with cellulitis of right lower leg due to Staph infection and was started on IV Rocephin. IV fluids and Insulin drip were started.
She was admitted to CCU.
Evaluation: Based on a physical exam she was a well developed, obese, elderly female, who was alert and oriented. Her Vital signs included: Temperature= 100, Pulse Rate=90, Respiratory =20 breaths per min, Blood Pressure= 150/88, Pulse OX=95 %, Weight= 190lbs, Height= 5’2’’. Patient complained her pain was a 5/10 in her right lower leg. Neck was supple, no jugular venous distention, no carotid bruit, no thyromegally. Multiple bruises noted on the arms. Right lower leg with an open wound with yellow discharge, area red, warm and tender to touch. Lungs are clear to auscultation bilaterally, heart sounds indicated a murmur, rate at 90, regular rhythm; abdomen is soft with tenderness at suprapubic region with left CVAT.
Assessment: Patient needs to be seen by cardiologist per her abnormal EKG, also blood sugar levels need to be regulated, and wound on right lower leg needs to be cleaned and evaluated for infection.
Nursing Diagnosis: Chest pain due to possible acute MI, Activity Intolerance due to obesity, Comfort is Impaired due to pain in chest and right lower leg wound, Risk for falls due to falls previously, Grieving for loss of husband, and Health maintainence compromised due to lack of dietary compliance.
Planning: Chief complaint of pain decreased by end of shift, make patient more comfortable, allow for proper procedures for risk of fall including: call light, bed rails, attentive staffing, further educate on diabetes and weight loss, plan for self- health management with family or social services.
Implementation: Maintain stable vital signs, Lower pain from 5/10 to 2/10 by end of shift, help patient into a comfortable position in bed allowing her comfort level to increase, Refer to cardiologist, refer to wound care specialist, educate patient on diabetes, weight loss, and maintaining her health management, educate family on compliancy of patient, refer to social worker if patients family is unable to help maintain regulating diabetes and falls.
Re-evaluate: Before patient leave make sure pain is lowered and is education on conditions.