Nursing Case Study: Management Of Assessment Answer

Nursing Diagnosis

Goal

Implementation

Rationale

Evaluate

1. Mild anxiety (post surgery and due to sweating)

(Zhou et al.2015).

The patient would be able to lessen her level of anxiety and relax.

·         Self-introduction between nurse and patient

·         Establishment of rapport

·         Explanation of procedure

When a patient-nurse relationship has been created along with the good rapport, then the nurse would be able to make the patient un

After few minutes of intervention, the patient relaxed, and her anxiety level was decreased.

2. Risk of infection

This is to avoid infection in the on going surgery

·         Rules of asepsis are applied

·         Assess for discoloration of skin

·         Signs of infection like redness, warmth

The asepsis rule must be known to all the nurses because it avoids the infection in the patient’s part and the infection signs are the onset of infection.

Post surgery, the patient should not show any sign of infection.

3. Deficient in knowledge of treatment, prognosis, and self-care

( Gulanick and Myers 2013). 

After an hour of implementation, the patient would be able to interrelate between signs and symptoms of the procedure.

·         Effects of surgery and future expectations are reviewed.

·         Resumption and encouragement of light activities like exercises are discussed.

·         Appropriate incisional care is reviewed.

It gives an idea of the knowledge base which could help the patient to make choices and also the strenuous activity causes fatigue which help in healing.

Since the patient knows the relation between the signs and symptoms, he also has actions to deal with them.

4. Reduced oxygen carrying capacity and haemoglobin level in the blood.

( Jain et al. 2016).

In a short term, the patient would show tolerance signs of physical activity and in long basis, a patient would report high energy level.

·         The ability pf the patient to perform the task is accessed.

·         Helps the patient to maintain the balance between rest and activity.

·         Identification of technique for energy saving.

The choice of intervention is influenced. The rest-activity balance reduces fatigue and promotes well-being. The technique of energy saving enables the patient to conserve much energy by doing a task.

After 8 hours of intervention, he The patient showed improved signs of tolerance and his energy level was also increased which made him independent.

5. Excessive loss of blood and deficit fluid volume during menstruation.

( Takemoto and Beharry 2015).

In a short term, the patient would be able to verbalize the blood loss and reduced fluid volume. On the long term, the patient would be shown ways as how to minimize blood loss by eating iron rich foods.

·         Monitoring of VS.

·         Calculation of blood loss by weighing all used pads.

·         Encouragement to eat iron rich foods.

VS monitoring would help in the establishment of baseline data nad keeping a check on used pads would help in monitoring blood loss from the patient. Iron rich food would replenish the blood lost during a menstural cycle.

The patient was able to understand that why she is having abnormal blood loss during her menstrual cycle and also how the lost blood could be made up by eating iron rich foods.

6.Fear of cervical cancer diagnosis

( Patricia et al. 2015).

During an intervention, the patient would be expressing her fear and concern for the diagnosis of cancer.

·         Alternatives to treatment with prognosis

·         Medications prescribed by physicians

·         Training on biofeedback and relaxation tricks.

The prognosis gives an idea to the patient about the full regime of the treatment, and the medications would provide him relief. The biofeedback would suppress his stress and increases the comfort level.

After few hours of intervention, the patient feels relax and shares his fears and concerns regarding the treatment.

7.Alteration of nutrition

 ( Sun et al. 2015).

In 2-3 days of nursing intervention, the patient should be able to understand the need for balanced diet and stable weight gain.

·         Intake of daily food is monitored

·         The patient is encouraged to eat food with high calorie and adequate fluid.

·         Adjustment of diet prior and after the treatment.

It helps in the identification of the deficiencies and strengths of the nutrients and eating encouragement fulfills the needs oof metabolic tissues and diet adjustment relieves the posttherapy nausea of the patient.

After the intervention, the patient understands the importance of balanced diet and also the weight gain for recovery.

8. Fatigue due to alteration in body chemistry.

( Borneman 2013).

Post 2 hours of intervention, the patient would express various activities to alleviate fatigue.

·         Identification of psychological and physical disease status.

·         Daily pattern is noted.

·         Instructions to skills of stress management.

The causative factors for the disease are accessed by the identification. The pattern determination helps to adopt various activities and stress management help to cope up with fatigue. 

After the intervention, the goal was met, and the patient was fully able to express the different activities.

9. Alteration in tissue perfusion related to hypovolemia.

After two days of intervention, the patient should show improved signs of tissue perfusion and increased blood circulation.

·         Factors related to thrombus history and emboli formation is determined.

·         Changes in the peripheral  regions such as circulation are identified

·         Calf massaging is discouraged.

The contributing factors for the disease are assessed by studying the history and discouragement of calf massaging helps in preventing immobilization.

After three days of intervention, the patient was able to relate his prior and after signs of tissue perfusion.

10. Anxiety for death related to stage Iv cancer and metastasis of liver and bone.

( Sommers and Fannin 2014).

After 6 hours of intervention, the patient should feel more safe and comfortable to discuss his fears and problems and be adjustable to the environment.

·         Patient’s grief is assessed.

·         The non-judgemental environment is provided.

·         The experience of patient's care is noted.

Knowledge of grief gives normal feeling to the patient, and past experiences gave clear perceptions which help in the treatment of the patient. The environment would give a realistic atmosphere to the patient about his concerns and fears.

The patient was more secure and safe in the environment and showed more compassion.