NURSING PROCESS WORKSHEETStudent Name:______________________________________ Identify the steps of the nursing process by placing the number after the appropriate activity in the following client situation. Each response is worth one point. 1=Assessment 2=Diagnosis 3=Planning 4=Implementation 5=Evaluation CASE HISTORYRobert, a 72 y.o. male is admitted with pneumonia. He reports that this is his second episode of pneumonia in 6 months.___ He complains of a frequent, hacking cough with a small amount of thick, greenish mucus.___ Auscultation of the lungs reveals scattered rhonchi throughout.___ His mucous membranes are pale and his lips are dry and cracked.____ You report these findings to the charge RN. The RN determines that Robert has ineffective airway clearance, fluid volume deficit, and a knowledge deficit that will require teaching to promote adequate self care and to prevent reoccurrence.____ The RN establishes the following outcomes: Client expectorates secretions completely with clear breath sounds. Client will have moist mucous membranes and loose respiratory secretions. Client verbalizes understanding of the cause of pneumonia and methods of prevention._____The RN sets up a regular schedule for respiratory activities and fluid replacement. _____ The RN also formulates a teaching plan to cover the identified concerns of self care and illness prevention.____ You provide a tube of lubricating jelly for Robert to use on his lips. Every two hours you visit Robert and encourage him to cough, deep breathe, change position, and to drink a glass of fluids._____ You use this time to discuss the avoidance of crowds and individuals with URIs._____ The following day, Robert’s skin is no longer hot and flushed with a temp of 99 degrees.____ Respiratory secretions are loose and readily expectorated. ______ Robert’s lips and oral mucous membranes are moist.____ Robert is able to explain, in his own words, how to care for himself and how to prevent pneumonia.____ You, together, with the RN, decide that the current treatment plan is achieving the identified outcomes and to continue the plan as written. ____ 16. One of your assigned patients has the following diagnoses. Which of the following diagnostic/problem statements is the top priority? A. Risk for infection B. Impaired gas exchange C. Impaired physical mobility D. Bathing self-care deficit Use only this info to write your interventions. Your patient is complaining of pain in her left knee due to an injury playing soccer. She rates her pain at a 5/10 and grimaces during ROM. 17-19. List three nursing interventions for the above patient: Remember this is what you did (past tense and specific) and when you did it. 1. 2. 3. 20. You determine that your interventions are not appropriate and not effective. After discussion with the RN, it is decided to try a different intervention. This step in the nursing process is ____________________________________. Rev. 8-22-21 Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
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