Question

Explain how the professional nurse utilizes the nursing process in the nurse-client relationship:

Mr. Samuel Lawson is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies. On admission, he states that he hasn’t been feeling well for 3-4 days, complained of dyspnea, generalized body pain, fatigue, and a productive cough of yellow colored sputum. He has not slept in 2 nights, is agitated, anxious about his health and reported feeling weak. Mr. Lawson has little appetite and is mostly eating soup even though the doctor ordered a regular diet. He is alert and oriented x 4, continent of bowel and bladder and on bed rest due to weakness and unsteady gait. Physical assessment reveals B/P 168/90; pulse 104; respirations 26; temperature 98.9 F; oxygen saturation 93% on o2 2L via NC with diminished breath sounds bilateral and expiratory wheezing on auscultation. Bowel sounds are present on all four quadrants, heart sounds are regular and his skin is intact. I.V. antibiotics are ordered and started.

Questions:

1a.) In a narrative explanation, explain the assessment phase of the nursing process and include objective and subjective questions for the holistic assessment (5 dimensions of man-see your care plan assessment sheet) of the patient including the vital signs.

1b.) Explain the diagnosis/analysis phase of the nursing process including the different types of diagnosis and generate three (3) priority nursing diagnoses for the patient based on the assessment data.

Answer 1

1a)Objective data is one what is observed and subjective data refers to what patient verbalize.Some of them in the assessment are as follows

Objective questions :

• Assess the vital signs (Temperature, Pulse,Respiration, BP)
• Auscultate the patients lung sound
• Facial grimace
• patient when coughs

Subjective questions:

• Patient expressing his pain level(using pain scale to assess (
• having poor sleep pattern(do you sleep adequately )
• difficulty in having food due to decreased appetite (how is your appetite )
• reporting of generalised weakness( are you able to perform your daily activities )

1b)The three priority nursing diagnosis are as following

• Ineffective breathing pattern/Impaired gas exchange related to constriction of bronchial walls as evidenced by hypoxemia ,tachycardia
• Imbalanced nutrition less than body requirement related to decreased appetite as evidenced by generalised weakness, fatigue
• Ineffective tissue perfusion related to vasconstriction as evidenced by increased blood pressure
• Disturbed sleep pattern related to disease condition as evidenced by lack of sleep