Included is a document: The nursing concept worksheet on which the work needs to be done .The goal is make sure to be precise with it and a certain time when the goal needs to be met. Also for the priority nursing diagnoses make sure its in the Nanda format.
Here’s a link of the NANDA FORMAT on how it should look:
For references put on a separate page.
Mrs. Smith is an 84-year-old female s/p spinal surgery (laminectomy) post op 3rd day. She is AxOx4, morphine 1mg IV for severe pain and oxycodone 5-10mg for mild to moderate pain, breathing fine without any need for oxygen inhalation. Her skin is warm and dry, intact except for the surgical incision on her back, covered with gauze and tegaderm. She was ordered a mechanical soft diet but her intake has been minimal. Patient voids in bed pan 3-4 times per shift, with no BM since surgery, has been (out of bed) OOB with the physical therapy to the chair. Patient has been reluctant to participate in the care due to her pain and prefers to stay in bed and sleep.
T – 98.7F, p- 75, bp- 136/73, pain – 9/10, r- 17, 02 – 97%. Clear lung sounds, abdomen soft, non-tender. Monitored, normal sinus rhythm. Mrs Smith has two daughters and 4grandchildren. She misses her family and would like to go home.
You are her nurse assigned for the day.
1. Assess and provide Priority Nursing Diagnoses (2) for this patient and at-risk nursing diagnosis (1)
2. What are your nursing interventions (with rationale) that you would provide for this post-op patient?
3. What are the post-operative complications that this patient may develop. Explain by giving reasons why they may occur.
4. What are the collaborative/interdisciplinary team members that are included in your care team? Describe their roles.
5. Describe your role in preventing post-operative complications for this patient.
Medical-Surgical Nursing: Assessment and Management of Clinical Problems
Author: Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Kwong, J., & Roberts, D.
Fundamentals of Nursing
Author: Potter, P., Perry, A., Stockert, P., & Hall, A.
Nursing Concept Map NURS 121L-A (2-20)