Medical Diagnosi s complet e SCOR E 7 GROUP 2 (PATIENT Y)


It as conside!ed to "a#e sco!e o$ 7 "ic" is %ES &eca'se t"e medical diagnosis is clea! eno'g" and it con$o!ms to t"e latest Inte!national classi$ication o$ Disease esta&lis"ed &( Depa!tment o$ )ealt". Ca!diac D(s!"(t"mia* +Inte!mittent, Ac'te At!ial Fi&!illation 1-... Unsta&le Angina 1/0.0 Co!ona!( a!te!( disease* Impai!ed diastolic $'nction I/1.1 Comm'nit( ac2'i!ed pne'monia J13.0 4!onc"iestasis J-7.. F'nctional Constipation 51..0 Insomia 6-7.0 Acid Related diso!de!78eptic 'lce! disease 5/7.9

/. O!de!s complet e


It as conside!ed to "a#e a sco!e o$ 7 "ic" is %ES &eca'se o!de!s e!e clea!: e;plicit and concl'si#e. It as e#ident in t"e docto!<s o!de! t"at s(mptoms &eing p!esented &( t"e patient and diagnosis a!e &eing add!essed. An e;ample t"at can &e gi#en is t"at to add!ess t"e c"est pain: Deponit 1mg 1 patc" no as o!de!ed. A medication $o! sin's &!ad(ca!dia as also gi#en: Amioda!one 900mg 100cc in 1 "o'!

t"en =00mg in /10cc D1> ; /- "o'!s. In compa!ison it" t"e docto!<s o!de! o$ t"e medication: t"e medication s"eet !e#eals t"e time o$ administ!ation as ell as i$ t"e patient !e$'ses t"e d!'g doc'mented as ?!e$'sed@. It is clea! to t"e $ollo ing medications $!om t"e nat'!e o$ t"e medication: as $o! Aact'lose: D'lcola;: B(Cast: A!i;t!a: Spi!i#a: and Motili'm to "a#e one dosage. All o!de!s e!e all 'p to date acco!ding to pe!tinent instit'tional o! agenc( polic(. All docto!s< o!de!s: t!eatments incl'ded t"e time and t"e date "en t"e( e!e iss'ed. All o!de!s e!e all 'p to date !ega!dless o$ t"e a#aila&ilit( o$ medications &'t t"e!e is no app!op!iate timing &et een t"e gi#ing o$ t"e o!de! and compliance it" it. T"e time it as e;ec'ted &( t"e n'!se as it"in 91D -1 min'tes $o! nonDstat o!de!s: /0D90 min'tes $o! stat o!de!s. An e;ample t"at can &e gi#en is t"at Spi!i#a as not gi#en on J'ne 90 and J'l( 1: it as indicated on t"e medication s"eet "ic" t"e time =pm as enci!cled &'t on J'l( 1 t"e!e is no time &eing enci!cle t"at it as not gi#en. Anot"e!: Aact'lose 90cc NO> as o!de!ed on J'l( / at 3*/0 8M and it as ca!!ied o't &( 3*-1 8M and gi#en at .*/08M. On J'l( 9: D'lcola; as o!de!ed / s'pp NO>: time it as ca!!ied o't as not indicated &'t it as onl( gi#en at 11*90 8M. Acco!ding to 4ON //0 A!ticle IE section 19:

9. O!de!s c'!!ent


-. O!de!s p!omptl ( e;ec'te d


RN m'st con$o!m to g!o'p acti#ities as t"ose o$ a "ealt" team s"o'ld &e &ased on accepta&le: et"icolegal standa!ds. A n'!se s"o'ld o!C in coo!dination and in solida!it( it" ot"e! mem&e!s o$ t"e "ealt" ca!e team in o!Cing $o! t"e patient<s &est inte!est. 1. E#idenc e t"at n'!se 'nde!st ood ca'se and e$$ect 7 T"e c"a!t "as s"o n t"at t"e n'!se Cne "at s"e as doing and "( s"e as doing it. S"e ill not gi#e an( medications it"o't Cno ing t"e ca'se and e$$ect o$ t"at se!#ice &e$o!e pe!$o!ming it. S"e pe!$o!med "e! $'nctions &( monito!ing #ital signs: p!omoting !est: inst!'cted t"e patient not to st!ain d'e to ca!diac p!o&lem+s,: p!omoting sa$et(: assessing al a(s t"e m'scle st!engt": c"anging position: inst!'cting to !epo!t 'nto a!d signs and s(mptoms: st!ict IFO: and administe!ed medication +Omep!aGole, as 1 "o'! &e$o!e meals $o! t"e !eason it ill ca'se 6I 'pset to t"e patient. Acco!ding to t"e p!inciple in Et"ics H Nonmale$icence is t"e d't( to ca'se no "a!m to ot"e!s. )a!m can taCe man( $o!ms* ps(c"ological: p"(siological: social: spi!it'al. Facto!s t"at n'!se m'st conside! !elated to t"is $'nction a!eI t"e t!eatment m'st o$$e! a !easona&le p!ospect o$ &ene$it and it m'st not in#ol#e e;cessi#e e;pense: pain: o! ot"e! incon#enience. +Daniels: /00-, T"e!e e!e no "isto!( taCen as doc'mented on t"e n'!se p!og!ess notes: Cno ledge: st!engt"s and eaCnesses e!e

=. E#idenc e t"at n'!se


tooC "ealt" "isto!( into acco'nt

not also assess "en planning t"e n'!sing ca!e to t"e "ealt" illness p!o&lem o$ t"e patient TaCing patient "isto!( is a!g'a&l( t"e most impo!tant aspect o$ patient assessment: and inc!easingl( &eing 'nde!taCen &( n'!ses. Man( n'!sing t"eo!ists "a#e e;amined "ealt" de$icits +)ende!son 1.==: Rope! et al 1..0: O!em 1..1,: all o$ "ic" !el( on ca!e$'l assessment o$ patients< needs. Ot"e! n'!sing t"eo!ists identi$ied inte!action t"eo!ies +8epla' 1.1/: O!lando 1.=1: 5ing 1.31,: "ic" so'g"t to de#elop t"e !elations"ip &et een t"e patient and t"e n'!se t"!o'g" s(stematic assessment o$ "ealt". II. OBSERVATION OF SYMPTOMS AND REACTIONS T"e!e is e#idence t"at t"e n'!ses 'nde!stand t"e disease o$ t"e patient. T"e n'!ses J'st $o! e;ample: "en t"e patient e;pe!ienced c"est pain: t"e( "ooCed into o;(gen #ia nasal cann'la "ic" is conside!ed as independent n'!sing inte!#ention "en t"e patient e;pe!iences c"est pain. >"en t"e patient also "ad at!ial $i&!illation: one n'!sing inte!#ention is connecting t"e patient in t"e ca!diac monito!. Most o$ t"e n'!sing inte!#entions done e!e !elated to t"e disease o! condition o$ t"e patient in gene!al. Acc!oding to Fa(e A&della": as a comp!e"ensi#e se!#ice: n'!sing incl'des t"e $ollo ing: !ecogniGing t"e n'!sing p!o&lems o$ t"e patient and deciding t"e


7. Related to t"e co'!se a&o#e disease in gene!al


app!op!iate co'!ses o$ action to taCe in te!ms o$ !ele#ant n'!sing p!inciples: p!o#iding contin'o's ca!e o$ t"e indi#id'al<s total "ealt" needs and to !elie#e pain and discom$o!t and p!o#ide immediate sec'!it( $o! t"e indi#id'al +6eo!ge: /00/,. 3. Related to t"e co'!se a&o#e disease in gene!al 7 T"e!e a!e doc'mented !esponses o$ t"e patient in t"e n'!ses< notes !ega!ding t"e inte!#entions gi#en: medical and n'!sing. T"e( "a#e doc'mented t"e p!og!ess in patient<s condition along it" t"e coping a&ilit( o$ t"e patient: J'st $o! e;ample: in t"e 1st da( o$ admission: it as doc'mented t"at t"e patient "as s'&Jecti#e !epo!ts o$ c"est pain: and in t"e $ollo ing s"i$ts: t"e( a!e also noting i$ t"e patient "as o! doesn<t "as c"est pain same as it" t"e ca!diac d(s!"(t"mias and e#ent'all( doc'mented t"at t"e patient is coping ell and "ad s'&Jecti#e !epo!ts $!om t"e patient t"at "e is a&le to eat and t"at t"e!e a!e no pain e;pe!ienced. It as also doc'mented t"at t"e patient as t"en a&le to alC alone: "o e#e! it as not doc'mented $!om t"e sta!t t"at t"e patient as 'na&le to do so o! is cont!aindicated to do as ell as t"e am&'lato!( stat's o$ t"e patient and t"e o!de!ed acti#it( o$ t"e patient. Acco!ding to Fa(e A&della"<s t"eo!( and n'!sing<s metapa!adigm: n'!sing is &!oadl( g!o'ped into t"e /1 n'!sing p!o&lem a!eas to g'ide ca!e and p!omote

t"e 'se o$ n'!sing J'dgment. N'!sing is also a comp!e"ensi#e se!#ice t"at is &ased on an a!t and science and aims to "elp people: sicC o! ell: cope it" t"ei! "ealt" needs +6eo!ge: /00/,. .. Related to t"e complicatio ns d'e to t"e!ap( 0 T"e!e a!e no !eco!ded o&se!#ations t"at a!e !elated to t"e e;pected t"e!ape'tic and possi&le o! 'ne;pected 'nto a!d side e$$ects. Fo! e;ample: in t"e application o$ deponit patc": t"e!e e!e no doc'mented !es'lts "et"e! it p!o#ided t"e!ape'tic e$$ect o! it !es'lted to 'nto a!d side e$$ect liCe "eadac"e. T"e!e a!e no doc'mented !eactions o$ t"e patient to t"e medications gi#en. Acco!ding to >eiden&ac": n'!sing as a p!actice discipline is goal o!iented. T"e n'!se t"inCs t"!o'g" t"e Cind o$ !es'lts s"e ants: gea!s "e! actions to o&tain t"ose !es'lts: t"en accepts !esponsi&ilit( $o! t"e acts: and t"e o'tcomes o$ t"ose acts. One o$ t"e components o$ n'!sing p!actice is t"e #alidation t"at t"e action taCen as "elp$'l to t"e patient. A$te! "elp "as &een ministe!ed: t"e n'!se #alidates t"at t"e actions e!e indeed "elp$'l. E#idence m'st come $!om t"e patient t"at t"e p'!pose o$ n'!sing actions "as &een $'l$illed +6eo!ge: /00/,. 100K o$ patient<s #ital signs e!e plotted and !eco!ded in t"e T8R s"eet e#e!( s"i$t: and $illedD'p it" app!op!iate data. T"e #ital signs plotted and !eco!ded in t"e T8R s"eet is cong!'ent in t"e doc'mented #ital

10. signs



11. 8atient to "is condition


signs in t"e n'!ses< notes. Some o$ t"e #ital signs taCen e!e also !e$lected o! doc'mented in t"e n'!ses< notes speci$icall( in t"e o&Jecti#e data. >"en t"e patient "ad e;pe!ienced &!ad(ca!dia: it as noted in t"e n'!ses< notes along it" t"e p'lse !ate and !"(t"m: and t"e 2'alit( o$ t"e !espi!ations. )o e#e!: in most o$ t"e n'!ses< notes: no $'!t"e! assessment !ega!ding t"e !ate: !"(t"m: and 2'alit( o$ p'lse e!e doc'mented "ic" is !elated to t"e $oc's p!o&lem o$ t"e patient liCe ca!diac d(s!"(t"mia +at!ial $i&!illation,. It o'ld &e "elp$'l in dete!mining p!og!ess in t"e patient<s condition and t"e elect!ical acti#it( o$ t"e "ea!t. T"e signs !e$lect c"anges in $'nction t"at ot"e! ise mig"t not &e o&se!#ed. Monito!ing a client<s #ital signs s"o'ld not &e an a'tomatic o! !o'tine p!oced'!eI it s"o'ld &e t"o'g"t$'l: scienti$ic assessment. Eital signs "ic" s"o'ld &e e#al'ated it" !e$e!ence to t"e client<s p!esent and p!io! "ealt" stat's: a!e compa!ed to t"e client<s 's'al +i$ Cno n, and accepted no!mal standa!ds +5oGie! and E!&: /003,. Upon admission t"e patient e;pe!iences pain: t"e #e!&al !epo!ts e!e taCen as ell as t"e pain !ate scale: "o e#e!: t"e!e e!e no doc'mented non#e!&al c'es and o! &e"a#io! !ega!ding t"e patient t"'s: no $'!t"e! in$o!mation as taCen !ega!ding t"e gi#en attention to t"e patient<s attit'de. T"e patte!ns o$ &e"a#io! c"a!acte!istic o$

1/. 8atient to "is co'!se o$ disease



19. E#idence t"at initial n'!sing diagnosis


t"e indi#id'al "a#e a p'!pose in t"e maintenance o$ "omeostasis &( t"e indi#id'al. Acco!ding to Jo"nson: n'!sing is an e;te!nal !eg'lato!( $o!ce "ic" acts to p!ese!#e t"e o!ganiGation and integ!ation o$ t"e patient<s &e"a#io! constit'tes a t"!eat to p"(sical o! social "ealt": o! in "ic" illness is $o'nd. N'!sing<s p!ima!( goal is to $oste! e2'ili&!i'm it"in t"e indi#id'al: "ic" allo s $o! t"e p!actice o$ n'!sing it" indi#id'als at an( point in t"e "ealt"Dillness contin''m +6eo!ge: /00/,. T"e!e a!e no doc'mentation !ega!ding t"e patient<s deg!ee o$ 'nde!standing and acceptance o! !eJection: o! am&i#alence to a!d "is condition and t"'s t"e!e a!e also no doc'mented attention gi#en to t"e attit'de o$ t"e patient. In A&della"<s patient cente!ed app!oac"es t"eo!(: t"e patient<s "ealt" needs can &e #ie ed as p!o&lems: "ic" ma( &e o#e!t as an appa!ent condition: o! co#e!t as "idden o! concealed on. 4eca'se co#e!t p!o&lems can &e emotional: sociological and inte!pe!sonal in nat'!e: t"e( a!e o$ten missed o! pe!cei#ed inco!!ectl(: t"'s implies a patientDcente!ed o!ientation +6eo!ge: /00/,. III. SUPERVISION OF THE PATIENT T"e c"a!t s"o s t"at initial n'!sing diagnosis as made &( t"e N'!ses "o "andled t"e patient. And t"ese diagnoses e!e dete!mined and catego!iGed as t"e &asis $o! n'!sing ca!e plans +AD8IE,

as made

di!ected to a!d sol'tion o$ t"e patient<s p!o&lems. T"e c"a!t s"o'ld "a#e initial diagnosis: &eca'se in t"e $o!mat c"a!ting o$ t"e "ospital +FDAR: SOA8IE,: t"e!e s"o'ld &e an identi$ied n'!sing diagnosis $o! t"at s"i$t. )o e#e!: t"e 'se o$ FDAR c"a!ting doesn<t !e2'i!e a n'!sing diagnosis &eca'se e#en a medical diagnosis is allo ed to &e a $oc's p!o&lem. UnliCe in t"e SOA8 c"a!ting.

1-. Sa$et( o$ t"e patient


T"e content o$ t"e c"a!t ma( #a!( depending on man( $acto!s. It can depend on t"e n'!se t"at is !iting t"e c"a!t: on t"e assessment $indings and on t"e $oc's p!o&lem identi$ied. Upon !e#ie ing t"e patient c"a!t: t"e!e is inconsistenc( o$ !eco!ded p!eca'tiona!( meas'!es in p!omoting t"e patient<s sa$et(. T"is s"o'ld not &e t"e case since acco!ding to Ei!ginia )ende!son: as a n'!se e s"o'ld meet t"e1- $'ndamentals and one o$ "ic" is a#oiding dange!s in t"e en#i!onment. T"e n'!se needs to ens'!e t"e sa$et( &( t"e 'se o$ di$$e!ent inte!#entions di!ected to a!ds it. And t"at: acco!ding to Maslo <s )ie!a!c"( o$ needs: sa$et( p!oceeds a$te! t"e p"(siologic need "ic" implies t"at it is !eall( necessa!( to implement inte!#entions to p!omote and ens'!e t"e

sa$et( o$ o'! patients. 11. Sec'!it( o$ t"e patient 0 T"e!e is negligi&le e#idence t"at t"e!e a!e !eco!ded meas'!es o! inte!#entions t"at "elps in maintaining a t"e!ape'tic en#i!onment $o! t"e patient +s'ppo!ting o$ p!od'cti#e inte!pe!sonal !elations"ip and gi#ing attention to t"e p"(sical setting in "ic" "'man inte!action occ'!, In Flo!ence Nig"tingale<s en#i!onmental t"eo!(: t"e en#i!onment is impe!ati#e to t"e "ealt" o$ t"e patient: t"at n'!sing s"o'ld s'ppo!t t"e en#i!onment to assist t"e patient in "ealing. In Maslo <s )ie!a!c"( o$ needs: sec'!it( is also p!io!itiGed ne;t to p"(siologic needs. T"at is "( alte!ing t"e en#i!onment to p!omote and ens'!e t"e sa$et( o$ o'! patient is #ital to t"ei! !eco#e!(. 1=. Adaptation T"e!e is signi$icant data to s'$$ice t"at t"e!e a!e attempts to "elp t"e patient adJ'st to "is c"anging condition: to t"e co'!se o$ "is illness: to "is ca!e: and to "is anticipated $'t'!e. >e s"o'ld &e patient cente!ed: and t!eat o'! patient "olisticall(. 4( gi#ing inte!#entions t"at "elps t"e

patient attain t"e!ape'tic goals e a!e p!omoting a "olistic app!oac" o$ ca!e &eca'se e a!e not me!el( add!essing p"(sical aspects &'t also t"e social emotional and spi!it'al aspects o$ t"e patient. 17.Contin' ing assessmen t o$ t"e patient<s condition and capacit( Upon !e#ie ing t"e c"a!t: t"e!e is e#idence o$ ongoing e#al'ation o$ c'!!ent stat's sit'ation o$ t"e patient and t"e a$$ects o$ ca!e: it" anal(sis o$ c'!!ent n'!sing p!o&lems. Assessment is #e!( essential in t"e n'!sing p!ocess: since e#e!( inte!#entions sta!ts and ends it" assessment. In t"e c"a!t: t"e!e is s'&stantiation t"at t"e!e is initial assessment as ca!!ied o't "o e#e!I t"e!e a!e negligi&le c'es o$ !eDassessment o! e#al'ation i$ t"e condition imp!o#es o! not. T"e!e is also e#idence o$ n'!sing ca!e plan modi$ications in acco!dance to t"e alte!ation o$ t"e n'!sing p!o&lems d'e to t"e c"anges in t"e patient<s condition and capacit(. N'!sing ca!e: &eing not onl( as "olistic t(pe o$ ca!e is a d(namic p!ocess. It is d(namic "ic" entail t"at e s"o'ld modi$( o'! plans "a!monio'sl( it" t"e c"anges in o'! e#al'ation and assessment

13. N'!sing plans c"anged in acco!danc e it" t"e assessmen t


$indings. 1.. Inte!action s it" $amil( and it" ot"e!s conside!ed 1 T"e c"a!t !e$lects t"at t"e!e is inade2'ac( o$ data t"at t"e!e is conce!n $o! t"e people in contact it" t"e patient it" a #ie to a!d p!omoting inte!actions t"at a!e &ene$icial to people conce!ned. T"is is t"e time t"at e incl'de ot"e! "ealt" ca!e p!o#ide!s: colla&o!ating it" t"em and also incl'ding t"e signi$icant ot"e!s in t"e plan o$ ca!e $o! t"e patient<s ell &eing. 4( t"is meas'!e e can s"o t"at e a!e ca!ing $o! o'! patients "olisticall(.


/0. Ca!e ta'g"t to patient: $amil(: o! ot"e! n'!sing pe!sonnel

IV. SUPERVISION OF THOSE PARTICIPATING IN CARE (EXCEPT THE PHYSICIAN) 1 T"e c"a!t +speci$icall( in t"e p!og!ess notes,s"o s e#idence o$ ca!e ta'g"t to patient: $amil(: n'!sing pe!sonnel and ot"e!s: s'c" maintaining calm and 2'iet en#i!onment: enco'!aging signi$icant ot"e!s to sta( on t"e &edside to p!omote sa$et(: a#oidance o$ st!en'o's acti#ities: alCing $o! less t"an $i#e min'tes: a#oidance o$ stim'lants s'c" as ca$$eine: alco"ol: to&acco: and to !epo!t 'nto a!d signs and s(mptoms liCe diGGiness: di$$ic'lt( o$ &!eat"ing: c"est pain: and t"e &ene$its o$ compl(ing to medical and n'!sing inte!#entions

/1. 8"(si cal: emotion al: mental capacit( to lea!n conside! ed


//. Conti n'it( o$ s'pe!#is ion to t"ose ta'g"t


Alt"o'g" t"e!e is e#idence o$ ca!e gi#en to t"e patient: t"e!e is not eno'g" e#idence o$ conside!ing t"e p"(sical: emotional: mental capacit( o$ t"e patient to lea!n. T"e patient as conside!ed as a ge!iat!ic indi#id'al "e!ein "e as add!essed acco!ding to "ealt" iss'es conside!ing some limitations o$ "is capacit( to pe!$o!m some tasCs &eing ta'g"t liCe "ea!ing impai!ment: slo ed mo#ement: and dependenc( to ot"e!s e!e also conside!ed "en p!o#iding ca!e. T"e c"a!t did not incl'de an( assessments !ega!ding t"e mental capacit( o$ t"e patient no! an( assessment on "o t"e patient "as ell 'nde!stood "is condition. It onl( $oc'sed on t"e p"(sical and emotional aspects o$ t"e patient. In t"e patient<s p!og!ess note: t"e!e is e#idence o$ contin'it( o$ s'pe!#ision to t"ose ta'g"t "ic" is also !eco!ded in most o$ t"e doc'mentations pe! s"i$t s'c" as !ein$o!cement o$ p!e#io's "ealt" teac"ings and inte!#entions. T"ese inte!#entions a!e !epeated pe! s"i$t to p!o#ide contin'it( and consistenc(. In t"e patient<s c"a!t: s'ppo!t is &eing gi#en &( p!o#iding t"e necessa!( ed'cation and inst!'ctions a&o't t"e patient<s condition: administe!ing medications and

/9. S'pp o!t o$ t"ose gi#ing



1" /-. Facts on "ic" $'!t"e! ca!e depende d e!e !eco!de d -

ot"e! p!oced'!es: and p!omoting sa$et(: com$o!t: and ell&eing. It as e#ident on t"e c"a!t +ed'cati#e, t"at n'!ses and st'dent n'!ses in$o!med o$ ta'g"t t"e signi$icant ot"e!s on t"e di$$e!ent inte!#entions t"at is app!op!iate to t"e condition o$ t"e patient s'c" as enco'!aging t"e patient to am&'late $!om "is !oom t"e n'!se<s station. V.REPORTNG AND RECORDING F'!t"e! ca!e as doc'mented in t"e patient<s p!og!ess notes &asing on t"e c'!!ent p!o&lem o$ t"e patient. 8atient as constantl( monito!ed on "is p!og!ess 'ntil t"e c'!!ent "ealt" sit'ation "as &een !esol#ed as e#idenced &( t"e doc'mentations and signat'!es o$ st'dent n'!ses: clinical inst!'cto!s: cle!Cs: inte!ns and p"(sicians on d't(. T"e in$o!mation !eco!ded s"o s t"e contin'ing p"(sician and n'!se management o$ clinical ca!e: as seen in t"e o&se!#ation o$ s(mptoms +as doc'mented pe! s"i$t and e#idence o$ e;ec'tion o$ docto!<s o!de! as J'sti$ied it" t"e p!esence o$ signat'!e o$ e#e!( o!de! signi$(ing t"at t"ese a!e p't into p!actice,. Signat'!es a!e p!esent in t"e O data o$ all t"e n'!ses< notes s'c" as le#el o$ conscio'sness: &lood p!ess'!e: and o;(gen sat'!ation.

/1. . Essentia l $acts !epo!ted to p"(sicia n


In t"e patient<s c"a!t: noticea&le and !epo!ta&le c"anges in t"e patient<s condition e!e !eco!ded in t"e p!og!ess notes: T8R s"eet: Inp't and O'tp't: as ell as in t"e Docto!s< o!de!s. It s"o s t"at &asic necessa!( in$o!mation as con#e(ed to t"e p"(sician eit"e! in !iting o! #e!&all(. It is t"ei! coope!ation it" t"e p"(sician and t"ei! management o$ t"e patient<s t"at maCes t"em essential o! 'nessential. T"e p"(sicians e!e in$o!med a&o't t"e essential $acts !ega!ding t"e p!esent "ealt" sit'ation o$ t"e patient. An e;ample o$ t"is is t"e a&sence o$ &o el mo#ement $o! t"!ee da(s "e!ein t"e Docto! p!esc!i&ed t"e necessa!( d!'g +Aact'lose 90 cc 8RN, to &e administe!ed to t"e patient to add!ess t"e c'!!ent p!o&lem $ t"e patient. T"e $acts !epo!ted to t"e p"(sician e!e e#al'ated "ic" is e#ident on t"e patient<s p!og!ess notes: T8R s"eet: Inp't and O'tp't: medication s"eet. T"e!e e!e e#idences s"o n $!om t"e patient<s c"a!t "ic" !e$lects an( e#al'ation o$ inte!#entions done to t"e patient t"at s"o i$ t"e patient<s condition imp!o#ed o! o!sened a$te! a t!eatment o! inte!#ention

/=. Repo !ting o$ $acts incl'ded e#al'ati on t"e!eo$


as gi#en. Once t"e c'!!ent p!o&lem is sol#ed: some inte!#entions t"e!e$o!e e!e te!minated s'c" as t"ediscontin'ing t"e Aact'lose 9Occ 8RN "en t"e patient !eac"ed t"e t"e!ape'tic e$$ect o$ t"e d!'g. Acco!ding to t"e T"eo!( o$ Ca!e: Co!e: C'!e o$ A(dia )all: e#al'ation is t"e p!ocess o$ assessing t"e patient<s p!og!ess to a!d t"e "ealt" goals. T"e e#al'ation p"ase o$ t"e p!ocess is di!ected to a!d deciding "et"e! o! not t"e patient is s'ccess$'l in !eac"ing t"e esta&lis"ed goals +6eo!ge: /00/,.

/7. 8atie nt o! $amil( ale!ted as to "at to !epo!t to p"(sicia n


In t"e patient<s p!og!ess notes: t"e patient is ale!ted to !epo!t signi$icant c"anges t"at t"e patient mig"t e;pe!ience s'c" as diGGiness: c"est pain: and eaCness. In t"e patient<s c"a!t: t"e!e a!e ed'cational inte!#entions done to t"e patient t"at t"e $amil( o$ t"e patient as ta'g"t on "at to !epo!t to t"e p"(sician. Also t"e signi$icant ot"e!s #e!&aliGed t"e in$o!mation !ega!ding t"e patient<s need $o! $'!t"e! ca!e and management. Acco!ding to t"e Inte!pe!sonal Relations in N'!sing o$ )ildega!d 8epla': t"e n'!se: t"e patient: and t"e $amil( o!C toget"e! to !ecogniGe: cla!i$(: and de$ine t"e e;isting

p!o&lem. S"e disc'ssed t"e need $o! t"e need to gi#e not onl( s'ppo!t &'t "ealt" teac"ing to $amil( mem&e!s +6eo!ge: /00/,. /3. Reco! d pe!mitte d contin'i t( o$ int!am'! al and e;t!am' !al ca!e It as !e$lected on t"e c"a!t t"at t"e!e as contin'it( o$ t"e se2'ence o$ ca!e $!om n'!se to n'!se: n'!se to p"(sician and n'!se $!om ot"e! p!o$essionals since t"e!e as c"a!ting e#e!( s"i$t and all t"e docto!<s o!de!s e!e ca!!ied o't. Contin'it( o$ int!am'!al and e;t!am'!al ca!e is e#ident since t"e c"a!t pe!mitted an 'ninte!!'pted se2'ence o$ ca!e $!om n'!se o! n'!se and n'!se to p"(sician: and $!om n'!se to ot"e! p!o$essionals as e#ident &( t"e s"i$t pe! s"i$t doc'mented as ell as t"e inte!#entions p!o#ided. Acco!ding to t"e T"eo!( o$ Ca!e: Co!e: C'!e 20 o$ A(dia )all: ca!e is t"e sole $'nction o$ n'!sing p!actice: "e!eas co!e and c'!e a!e s"a!ed it" ot"e! mem&e!s o$ t"e "eat" ca!e team +6eo!ge: /00/,. VI.APPLICATION AND EXECUTION OF NURSING PROCEDURES AND TECHNI#UES / .1K o$ t"e p!esc!i&ed medications e!e administe!ed on t"e !ig"t time: !ig"t dosage and !o'te: e;cept "en t"e patient !e$'ses to &e gi#en D'a#ent in"ale! 1 p'$$ OD and Spi!i#a 1 p'$$ OD $o! 9 da(s and Da&igat!an 1 ta& 4ID as not also administe!ed ma( &e &eca'se t"e


/..Adminis t!ation and7o! s'pe!#ision o$ medication s

medication as not a#aila&le at t"at time: t"'s missing "is $i!st dose o$ it. T"e t"e!ape'tic e$$ects and !isCs o$ not taCing t"e 4!onc"odilato! medications s"o'ld "a#e p!ope!l( e;plained to t"e patient and SO so t"at t!'st and compliance ill &e !egained and t"e incidence o$ !e$'sing s'c" medication $o! consec'ti#e 9 da(s ill &e a#oided. 4't d'!ing t"e con$inement o$ t"e patient: common side e$$ects o$ t"e medications s'c" as c"anges in 48: CR:RR e!e closel( monito!ed: sa$et( as also ens'!ed t"!o'g" !aising sideD!ails d'e to dec!ease in AOC as sideDe$$ect o$ t"e medications taCen: patient as also inst!'cted to !epo!t 'nto a!d signs and s(mptoms and sideD e$$ects o$ t"e medications to atc" o't $o!. In as also doc'mented in t"e medication s"eet "o administe!ed t"e d!'g. Acco!ding to 4e"a#io!istic T"eo!(: positi#e attit'des s"o'ld &e !ein$o!ced: as to t"e case patient compliance to medications. 90. 8e!sonal ca!e +&at"ing: o!al "(giene: sCin: nail 0 D'!ing t"e con$inement it as not doc'mented i$ t"e patient: $amil(: no! t"e "ealt" ca!e p!o#ide!s p!omoted t"e patient<s "(giene and pe!sonal ca!e: p!omotion o$ cleanliness: &at"ing: g!ooming: sCin and nail ca!e: etc. Acco!ding to Ei!ginia )ende!son: 1 o$ t"e

ca!e: s"ampoo,

component o$ 1- &asic n'!sing ca!e is to Ceep t"e &od( clean and ell g!oomed and p!otect t"e en#i!onment +6eo!ge: /00/,. / Ao salt: lo $at: lo ca!&o"(d!ate as t"e diet o!de!ed $o! t"e patient &eca'se patient as diagnosed o$ ca!dio#asc'la! p!o&lems and "e is al!ead( 77 (ea!s old "e!ein $at meta&olism is al!ead( inade2'ate "ic" co'ld ca'se $at deposition in a!te!ies: and salt intaCe s"o'ld &e !eg'lated so as to dec!ease o!C load o$ t"e "ea!t since salt att!acts ate!: ca'sing g!eate! &lood #ol'me "ic" t"en ca'ses g!eate! ca!diac o!Cload. 8atient<s special diet as gi#en app!op!iate attention d'!ing t"e co'!se o$ con$inement and "ealt" ed'cation d'!ing disc"a!ge pe!iod. Sel$ Ca!e De$icit N'!sing T"eo!( e;plains t"e need $o! a s'$$icient intaCe o$ $ood +6eo!ge: /00/,. Fl'id and elect!ol(tes e!e p!ope!l( o&se!#ed. D'!ing admission patient<s se!'m NA and 5 e!e taCen in o!de! to o&se!#e $o! possi&le elect!ol(te im&alances. Int!a#eno's $l'ids e!e also gi#en not also $o! access o$ medication &'t also to maintain "(d!ation and $l'id stat's o$ patient. IntaCe and o'tp't e!e closel( monito!ed d'e to patient<s ca!diac p!o&lem

91. N't!ition +incl'ding special diets,

9/. Fl'id &alance pl's elect!ol(tes


and age. A&della"<s /1 N'!sing 8!o&lems incl'de t"e need $o! t"e maintenance o$ $l'id and elect!ol(te &alance +6eo!ge: /00/,. 9-. Rest and sleep / Since t"e patient "as Ca!diac D(s!"(t"mia* Ac'te At!ial Fi&!illation: patient de#elops dec!ease in ca!diac o'tp't ca'sing eas( $atiga&ilit( and m'scle eaCness. T"'s as independent inte!#entions: n'!ses and st'dent n'!ses p!omoted ade2'ate time $o! !est and pe!iods: cl'ste!ing acti#ities and dec!easing en#i!onmental stim'li d'!ing t"e "ole co'!se o$ con$inement. Sel$ Ca!e De$icit T"eo!( o$ Do!ot"ea O!em incl'des maintenance o$ a &alance &et een acti#it( and !est +6eo!ge: /00/,. D'e to patients ca!dio#asc'la! p!o&lem: 'pon admission patient as o!de!ed to "a#e C4R it"o't 4R8s: a$te! / da(s patient as o!de!ed to "a#e C4R it" assisted 4R8s and = min'te alC test i$ 'pon 1/A EC6 t"e!e is no!mal sin's !"(t"m. A$te! 1 da( patient !es'med C4R it"o't 4R8s ma(&e &eca'se o$ possi&le o&se!#ed alte!ation in elect!ical acti#it( o$ t"e "ea!t 'pon inc!eased mo&iliGation. T"ese c"anges in o!de! !e$lect attention and conce!n on patient<s capacit( and tole!ance in p"(sical acti#ities. T"e!e is no &alance &et een p"(sical acti#it( and !est:

91. 8"(sical acti#it(


9=. I!!igation


97. D!essings and &andages 93. Fo!mal e;e!cise p!og!ams



&'t conside!ing patient<s condition it is onl( a matte! o$ eig"ing !isC and &ene$its. A&della"<s /1 N'!sing 8!o&lems incl'de t"e need to p!omote optimal acti#it( and e;e!cise +6eo!ge: /00/,. 8atient does not "a#e i!!igation $!om o'nds: s'!gical p!oced'!e: canals: ca#ities: etc. 8atient de#eloped constipation &'t as not o!de!ed to "a#e enema: ma( &e &eca'se enema ca'ses #agal episodes and d(s!"(t"mia: "ic" in t"e case o$ t"e patient s"o'ld &e a#oided. 8atient does not "a#e an( o'nd and d'!ing t"e co'!se o$ con$inement "e did not "a#e an( p!ess'!e so!es o! an( &!eaC in t"e sCin integ!it(: t"'s d!essings and &andages a!e not indicated. A$te! / da(s o$ con$inement patient as o!de!ed to "a#e = min'te alC test on medical inte!ns i$ 'pon 1/A EC6 t"e!e is sin's. Onl( 1 session o$ = min'te alC as ca!!ied o't: and C4R it"o't 4R8s as !es'med. Facto!s cont!i&'ting to t"e discontin'ation o$ t"e test e!e not doc'mented &( t"e assigned st'dent n'!seI t"e!e e!e no assessment: s'ppo!ti#e enco'!agement: no! assistance done to t"e patient a$te! t"e session. A&della"<s /1 N'!sing 8!o&lems incl'de t"e need to p!omote optimal acti#it( and e;e!cise +6eo!ge: /00/,.

9.. Re"a&ilitati on +ot"e! t"an $o!mal e;e!cise,


-0. 8!e#ention o$ complicatio ns and in$ections


8atient is 'nde! C4R it"o't 4R8s: t"'s &eca'se o$ t"is limitation in acti#it(: "ealt" ca!e p!o#ide!s s"o'ld "a#e p!omoted acti#e and passi#e e;e!cises and independence in ADAs t"at can &e tole!ated. D'!ing t"e co'!se o$ con$inement: t"e!e e!e no doc'mented pe!$o!mances o$ acti#e and passi#e e;e!cises &( t"e "ealt" ca!e p!o#ide!s. )ealt" ed'cation it" !ega!ds to impo!tance o$ e;e!cises and mo&ilit(: complications did not associate it" immo&iliGation no! e!e positi#e !ein$o!cements and p!omotion on acti#ities t"at can &e tole!ated not also done. Ca!e: Co!e: C'!e T"eo!( o$ A(dia )all stated t"at n'!ses s"o'ld "elp t"e patient and $amil( t"!o'g" medical: s'!gical and !e"a&ilitati#e p!esc!iptions made &( t"e p"(sician+6eo!ge: /00/,. Standa!d p!eca'tiona!( meas'!es s'c" as "and as"ing to a#oid c!oss contamination as not st!ictl( done as e#idenced &( a&sence o$ doc'mentation "and as"ing done &e$o!e and a$te! "andling patient no! "ealt" teac"ing !ega!ding impo!tance o$ "and as"ing done &( t"e assigned st'dent n'!ses and n'!ses. Especiall( in t"e case o$ t"e patient "e!ein "e as diagnosed o$ Comm'nit( Ac2'i!ed 8ne'monia: "ealt" ca!e p!o#ide!s and SO

-1. Rec!eation and di#e!sion


a!e at !isC o$ cont!acting t"e disease. F'!t"e!mo!e t"e patient is imm'ne comp!omised: t"'s patient s"o'ld also p!omote in$ection cont!ol. Acti#e and passi#e e;e!cises e!e not also pe!$o!med and enco'!aged. T"o'g" t"e!e e!e no doc'mented c!oss in$ection: $o!mation o$ &ed so!es: m'scle asting no! cont!act'!es: "ealt" ca!e p!o#ide!s still e!e not a&le to p!ope!l( p!omote "ealt" teac"ings !ega!ding p!e#ention o$ t"ese complications. Acco!ding to T"eo!( o$ modelling and !oleD modelling n'!ses a!e !e2'i!e to se!#e as a model and pe!$o!m inte!#entions to in$l'ence client<s pe!specti#e +6eo!ge: /00/,. A&della"<s /1 N'!sing 8!o&lems incl'de also t"e need to maintain good &od( mec"anics and p!e#ent and co!!ect de$o!mities +6eo!ge: /00/,. T"e!e e!e no doc'mented inte!#entions t"at o'ld p!omote !ec!eation and di#e!sional acti#ities to t"e patient: especiall( t"at t"e patient is 'nde! C4R it"o't 4R8s: acti#ities a!e #e!( limited and patient co'ld de#elop &o!edom and lacC o$ inte!est in t"e s'!!o'nding: "ealt" ca!e p!o#ide!s and t"e medical and n'!sing inte!#entions t"e( pe!$o!m: p!omoting an en#i!onment not cond'ci#e $o! t"e patient. A&della"<s /1 N'!sing 8!o&lems incl'de

-/. Clinical p!oced'!es D'!inal(sis: 48


-9. Special T!eatments +e.g. ca!e o$ t!ac"eotom (: 'se o$ o;(gen: colostom( o! cat"ete! ca!e: etc., --. 8!oced'!es and tec"ni2'es ta'g"t to patient


also t"e need to c!eate and maintain a t"e!ape'tic en#i!onment +6eo!ge: /00/,. All !es'lts o$ EC6 e!e attac"ed to t"e c"a!t $!om t"e time o$ admission. Ca!diac monito! as also monito!ed closel(: and an( alte!ation as doc'mented: !e$e!!ed: and gi#en medical and n'!sing inte!#entions. Eital signs especiall( t"e &lood p!ess'!e as closel( monito!ed &( st'dent n'!ses and n'!ses: especiall( most o$ t"e time 48 is &e(ond no!mal and t"e medications &eing administe!ed g!ossl( a$$ect 48 and also CR. 8atient "as o;(gen in"alation pe! nasal cann'la at 1A8M d'e to c"est pain as a !es'lt o$ dec!eased tiss'e pe!$'sion on m(oca!dial tiss'es. Use o$ o;(gen de#ice and ca!diac monito! as p!ope!l( monito!ed and doc'mented. N6T $eeding is not indicated &eca'se t"e patient is a&le to tole!ate $eeding pe! o!em. Colostom( and IFC as not also o!de!ed &eca'se patient can still cont!ol &ladde! and &o el mo#ement. T"e!e e!e no "ealt" ed'cations to patient o! SO done !ega!ding inc!easing independence in sel$ ca!e and ADAs: it"in t"e patient<s tole!ance and limitations.




-1, 8lans $o! Medical Eme!genc(


-=, Emotional s'ppo!t $o! t"e 8atient


-7, Emotional S'ppo!t to t"e Famil(


VII. REPORTING AND RECORDING T"e!e e!e no gi#en di!ection o! teac"ing a&o't t"e di$$e!ent possi&le medical eme!gencies t"at t"e patient ma( &e at !isC $o!.On t"e patient<s &ill o$ !ig"ts: patients "a#e t"e !ig"t to !ele#ant: c'!!ent and 'nde!standa&le n'!sing diagnosis and !isC in#ol#e. >e s"o'ld in$o!m t"em o$ impo!tant teac"ings it" !ega!ds to t"ei! p!esent condition: on p!eca'tions and s"o'ld incl'de di$$e!ent eme!genc( p!otocols o$ t"e "ospital. Some o$ t"e n'!se<s notes !e$lected e#idence o$ p!o#iding emotional s'ppo!t to t"e patient "e!ein t"e patient as enco'!aged to #e!&aliGe "is $eelings &'t is not eno'g". Acco!ding to A&della"<s /1 n'!sing p!o&lems t"eo!(: it is necessa!( $o! 's to accept positi#e and negati#e e;p!essions and !eactions $!om patient<s e a!e ca!ing $o!. T"e!e as no doc'mentation t"at o'ld !e$lect an e#idence t"at emotional s'ppo!t as gi#en to t"e signi$icant ot"e!s o$ t"e patient It is impo!tant to conside! ot"e! se!#ices t"at e can p!o#ide to t"e patient. Acco!ding to t"e A&della"<s /1 n'!sing p!o&lems: t"e!e a!e t"!ee maJo! catego!ies o$ "at t"e patient needsI p"(sical: sociological and emotional. It is t"en necessa!( $o! 's n'!ses to s'ppo!t t"e

sociological needs o$ t"e patient &( also gi#ing emotional s'ppo!t to t"e $amil( $o! t"em to s'ppo!t t"e patient. -3, Teac"ing 8!e#enti#e "ealt" ca!e 0 T"e patient is ta'g"t on di$$e!ent s(mptoms t"at ma( indicate o!sening p!o&lems o! an a!ising complication e#idenced &( doc'mentation on t"e n'!se<s notes. It is doc'mented on t"e patient<s c"a!t t"e patient as gi#en ed'cation on 'nto a!d signs and s(mptoms to atc" o't $o!. In )all<s Ca!e Co!e C'!e t"eo!(: t"e pe!son is t"e Co!e: t"e patient. T"e patient sets goals &( "imsel$: so necessa!( teac"ing is impo!tant so t"at t"e patient ma( &e g'ided. -., E#al'ation o$ t"e need $o! additional !eso'!ces: incl'ding spi!it'al g'idance: social se!#ices: occ'pation al t"e!ap( o! contin'it( o$ n'!sing ca!e 'nde! 0 T"e!e as no e#al'ation done $o! t"e need o$ additional !eso'!ces: incl'ding spi!it'al g'idance: social se!#ices: occ'pational t"e!ap( o! contin'it( o$ n'!sing ca!e 'nde! anot"e! aegisI )omemaCe! Se!#ice. No e#idence &( doc'mentation o! e#en c'es as not p!esent to indicate t"e e#al'ation. Acco!ding to Roge!<s t"eo!( o$ t"e science o$ Unita!( )'man 4eings: t"e patient: o! t"e pe!son s"o'ld &e seen as in 'nison it" t"e en#i!onment: t"'s: ca!e s"o'ld not &e 1 sided and s"o'ld &e "olistic. Ot"e! $o!ms o$ s'ppo!t to t"e patient s"o'ld &e incl'ded in t"e case.


anot"e! aegisI )omemaCe ! Se!#ice. 10, Action taCen in !ega!d to needs identi$ied. 9 Actions taCen in !ega!d to needs identi$ied e!e e#ident and doc'mented in t"e n'!se<s notes. Di$$e!ent c"anges in acti#it( le#els o$ t"e patient as p!ope!l( identi$ied and add!essed &( t"e n'!se. 8!ope! inte!#entions e!e done and t"e n'!se as a&le to identi$( n'!sing diagnoses on state o$ t"e patient a$te! t"o!o'g" assessment.


Acco!ding to Maslo <s "ie!a!c"( o$ needs: it is impo!tant to seeC and add!ess $i!st &asic needs &e$o!e "ig"e! needs in a $o!m o$ a "ie!a!c"(. It as s"o n in t"e n'!se<s notes 3 t"at p!io!it( needs e!e $i!st add!essed. 121.$ GOOD 3


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