Use of the Nursing Process to Care for a Complex Patient

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Topic 1: Use of the Nursing Process to Care for a Complex Patient

Ms. Janet Smith is a 45-year-old African-American female who was admitted to a medical/surgical unit with a diagnosis of infection secondary to removal of ovarian cysts 1 week ago. Past medical history includes hypertension and diabetes mellitus Type 2. She also admits to a non-healing wound on her right toe, approximately 2cm x 2cm, red, swollen, with purulent drainage present on dressing. Home medications include enalapril (Vasotec) 5 mg PO BID, multivitamin one tablet daily, and insulin glargine (Lantus) 24 units subcutaneously QPM. Admission assessment data includes abdominal incision site warm to touch, erythematous, with small amount of purulent drainage on dressing. Patient rates pain of abdominal wound as 5 out of 10 on a 0-10 scale. She states the pain from her toe is an 8 out of 10 on a 0-10 scale. Admitting vital signs are: Temperature 99.7 F, oral, pulse 89, respirations 20, blood pressure 178/95, SpO2 97%, room air.

 

Admitting orders are as follows:

 

Admit to medical unit

Full Code

Allergies: sulfa, eggs

Activity, up with assist

Contact precautions

Enalapril (Vasotec) 5 mg PO BID

Multivitamin 1 tablet PO daily

Lantus insulin 24 units subcutaneous QPM

Fingerstick blood glucose AC & HS

Humalog insulin per sliding scale protocol

0.9% normal saline at 125 mL/ hr

Culture toe ulcer and abdominal wound STAT

Cefazolin (Kefzol) 1 gram in 100 mL IVPB Q8H

Acetaminophen 1000 mg PO Q6H prn pain

Wound consult

Blood cultures x 2 now

Enoxaparin 80 mg subcutaneously BID

CBC with differential, CMP, BNP, Hgb A1C now

CBC with differential, BMP in AM

1. What are the top three highest priority nursing diagnoses for this patient?

2. For the diagnoses you identified, create a list describing subjective and objective assessment data associated with the diagnosis and a plan of care for each nursing diagnosis.

3. Describe the methods that will be used to evaluate care given. Include a timeline, methods of gathering data, and benchmarks indicating success.

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