Nursing Assessment

[malkieh]

I need a fake nursing assessment so that I can categorize it into orem's

Any suggestions on where I can find something like that???

[achot]

Impaired nasopharygeal perception (inability to smell/ taste)?
Or really fake like:
Inability to return chairs to table (my children... even though I understood my daughter was complimented last Shabbat for doing so at her friends home)
Chavie

[medic09]

Chavie, that must be 'Percieved Inability...'. ;D

Funny, my mother would get compliments about what a nice helpful boy I was at the neighbor's house and wonder, 'are we talking about the same boy?'

[malkieh]

I know how to do a nursing care plan and nursing diagnosis..

They want us to take an assessment i.e.

80 year old man................

Then I have to categorize it by

Air

Water

etc
etc.


I just need a fake scenario so that I can practice the categorizing, as we have an exam on it next week....thanks

[medic09]

Okay, like this?

80 yo man brought to the hospital ED. Conscious, Alert, Oriented to person, but mildly confused about time and place. Fairly passive.

General appearance: Very mildly distressed and mildly confused. Cooperative. Skin warm to touch. Skin brittle, but no open wounds. Skin turgor poor, with mild tenting. Color pale, dusky around lips and nail beds. Grooming a bit neglected, but not grossly so. Caregiver reported to EMS he 'hasn't been himself'. Appears adequately nourished, though thin. Recently diminished appetite and intake per caregiver to EMS.

Moves all extremeties freely. Weight bearing with assistance for balance.

Lung sounds: Moving air in all fields, maybe diminished in left lower lobe. Hard to tell. Shallow breaths. No apparent respiratory distress. No wheezes, rhonchi, etc.

Radial pulses present, equal, fairly strong, regular. Heart sounds S1, S2. Cap refill about 2 seconds at hands and feet.

Bowel sounds present, normoactive.

Patient wearing adult diaper which is moist.

Vitals: BP 98/54 HR 112 RR 20 SaO2 87% on Room Air Temp 39 C Oral.

NKDA. Meds: something for the heart (beta blocker? other?). Not known how compliant or not. Negative Pertinent known medical history.

Did you want something that clinical? Or do you need something more leading to 'nursing diagnoses'?

BTW, we continue to use scenarios and real cases for review and challenge. And example of what I do is the case presentations/challenges at FlightWeb.com, in the forums under Case Presentations. It's mostly medical presentations, because we don't do much continuous nursing. Go look and challenge yourselves!

Shabbat Shalom!

[malkieh]

something more leading to a nursing diagnosis... very nice website you sent me to but, I am too new to nursing to toy with that.

anything else?

[malkieh]

so from the scenario you posted I got the following did I miss anything??

A. Universal self-care requisite
a. Air - rr- 20, SaO2 87%, shallow breaths, LLL maybe diminished, no wheezing, or resp distress

b. Water – BP 98/54, HR 112, Temp 39, pulses normal, skin warm to the touch, Skin turgor poor, with mild tenting. Color pale, dusky around lips and nail beds


c. Food – diminished appetite, adequate – but thin


d. Elimination – bowel sounds present, normal, incontinent (wearing a diaper)

e. Activity - moves extremeties freely, needs assistance in weight bearing

f. Solitude – social interaction


Protection from Hazards (prevention of hazards to life functioning and well being)
g. Personal safety practices
h. Social habits
i. Health Habits/health resources and personal health practices
Confused about time and place


Sense of normalcy (the promotion of human functioning and development within social groups in accord with human potential, known human limitations and the human desire to be normal)
j. Self concept
k. Spirituality

Care giver

Are there any deficits or risk factors for deficits?

If yes, identify the deficits or risk factors.



B. Health deviation self-care requisite
a. Present deviation incontinence – wearing a diaper, weight bearing assistance needed
i. Perception of deviation - needs assistance ambulating
ii. Coping mechanism
iii. Effects on deviation on life styles
b. Past history of health deviations (include medications)

Mildy confused, passive

c. Family health history

Not sure of medications or if compliant

C. Developmental self-care requisite

Maturational events – 80 years old



Situational events


Are there any deficits or risk factors for deficits?

If yes, identify the deficits or risk factors


D. Questions/Issues to clarify or validate

[Rivka P]

malkie, I have never seen a patient profile categorized in that way. I imagine it's something that your teacher is having you do as an exercise, to help you analyze the situation. It may also be a good way to organize reporting off to the next nurse.

[malkieh]

does it look like I missed anything?

[Rivka P]

no I think it's all there. I am sure that I am jumping the gun, but I can tell you almost for sure that this man is dehydrated and I suspect he has a UTI. ;-)

[malkieh]

thank you rivka, I missed that!

Anyone else? I cannot diagnose a UTI, we are not allowed to use medical definitions. it would have to be fluid volume deficit

[medic09]

Rivka is right. This is a very typical elderly UTI patient. I see them every week in the ED.

You may not use medical diagnosis in school, but knowing what it likely is can help with your nursing plan as well.

What, btw, is an OREM ?

I see you're using a sensible outline, but not NANDA nursing diagnoses. I hated the nursing diagnosis, myself.

Looks like you did pretty well. Even a medical presentation like I gave has plenty in it for a nursing approach. In my particular jobs, the nurses tend to work medically anyway; so I was more inclined to think of that sort of patient.

This patient has an SaO2 well below normal. Since he isn't a COPDer, that is a big red flag. He has a respiratory impairment and oxygen deficit of some kind. Your other big clue for that is the dusky lips and nailbeds. Put that into 'nursing terms'. That, btw, would have to be addressed immediately on a live patient, while you're thinking of and checking other things.

His confusion may be from lack of oxygen, may be from low blood sugar (you would check that soon), may be from the effects of infection, may be from hypovolemia. Confusion creates a safety risk. Couple that with the poor balance, and you have a fall risk. Can't leave this patient alone for long. The poor grooming may be connected to all this, or maybe he really is beginning to neglect himself. That would be a risk/deficit to follow up on. Put it in nursing terms.

You already understood that the poor skin turgor and color from hypovolemia means volume/fluid deficit to you.

Those vital signs say fever/infection/maybe hypovolemia. BUT, his infection may already be approaching sepsis. BP is getting mild. HR is a little tachy; maybe he can't compensate further. I know that's all medical, but you will see it. This is a sick patient with the potential for getting much sicker rapidly. And a very typical patient, I might add.

Meds. Needs follow up. We have no clue what is inside him, and what he normally needs. Once he is clearheaded (IF) we may determine if there is a knowledge deficit about his meds and how he should take them, etc. Not an uncommon problem.

Okay, now I really will say Shabbat Shalom!

Let us all know how we may help further!

[malkieh]

yup!

Our nursing program uses Orem's framework

This is the worksheet we are given to cluster data to figure out what is the most important thing to focus on first.

In your patient's case it would be O2 saturation, because he has to have good oxygen in the body.

[Rivka P]

en.wikipedia.org/wiki/Orem_model_of_nursing

[Rivka P]

if we are going for nanda's, i think you might want to add ineffective airway clearance or impaired gas exchange