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NURSING PROCESS PAPER

Nursing Process Paper

By: Alysia Brillhart

NRS 201

Instructor: Melanie Milbrodt

Due Date: 3/14/2021

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The nursing process is a nursing skill used to determine the most effective plan of care

for individual patients. The first step of the nursing process involves assessing the patient, which

includes their demographic data, medical and social history, subjective/objective data, lab values

that were obtained, diagnostic examinations that were performed, orders for activity and

nutrition, along with medications that the patient is taking. The second step of the nursing

process involves diagnosis, which allows for the nurse to utilize critical thinking skills to identify

what the individual patient’s problems/diagnoses are after completing the assessment. The third

step of the nursing process involves planning, which includes identifying patient problems and

coming up with a plan to address those problems. This step includes coming up with nursing

diagnoses revolved around the patient problems, determine patient centered short-term and long-

term goals and planning nursing interventions for each patient problem. The fourth step is

implementation, which involves putting the nursing interventions into action and performing

them to help meet the patient outcomes to promote the patient’s overall health. The fifth and

final step of the nursing process is evaluation. During the final step, the nurse reviews the overall

plan of care for the individual patient and determines whether nursing diagnoses and nursing

interventions helped meet the patient centered goals. During this step, the nurse can also offer

suggestions as to how the care plan could be made more efficiently, such as implementing a

more appropriate intervention. Overall, the nursing process is a great tool to use to formulate a

patient centered plan of care.

For the purpose of this nursing process paper, we were asked to develop an evidence-

based plan of care for a patient we cared for during our NRS 201 clinical. For this project, I

obtained assessment data through the head-to-toe assessment I performed on my patient,

gathered medical/social history, obtained laboratory values that were drawn, viewed diagnostic
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procedures that took place, activity and nutrition orders that were initiated and medications that

my patient was taking. I was able to utilize this information to come up with patient centered

nursing diagnoses, along with an overall plan of care for my chosen patient. Later on in this

paper, I will relate the goals of Healthy People 2030 to the care I provided to my chosen patient.

On 2/22/21, I had the opportunity to utilize the nursing process during my care for a

patient who had an extensive renal related medical history. The patient’s initials were D.H. and

she was a 72-year-old Caucasian female. According to the patient’s chart, she did not have any

religious affiliation and the level of education that she completed was a high school level of

education. Before she retired, she worked at a grocery store as a cashier. The current place at

which she was residing was an assisted living facility. She did not have any children, she was

a widow and she didn’t have any visitors during her hospital stay. These factors played a role in

the patient’s plan of care because the patient had no means of a support system or advocacy other

than nursing staff.

D.H.’s reasoning for seeking medical care was due to becoming hypotensive,

hypoglycemic and having an altered mental status while at dialysis. D.H. was having visual

hallucinations and was seeing objects that weren’t really there during dialysis treatment. Upon

D.H.’s arrival to the emergency department at Aultman, it was found that the she had a urinary

tract infection (UTI) and sepsis. D.H.’s past medical history included chronic anemia,

gastroesophageal reflux disease (GERD), end stage renal disease, chronic kidney disease,

chronic venous stasis, Type 2 Diabetes Mellitus, idiopathic cirrhosis, depression, anxiety,

hypertension, peripheral neuropathy, osteoporosis, arthritis, pancytopenia and degenerative disc

disease. The patient’s extensive medical history, especially the end stage renal disease, impacted

her plan of care because goals set for the patient were harder to obtain due to her kidneys already
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failing. Unfortunately, that meant that her kidney disease was irreversible at that point.

Additionally, since she had a UTI and sepsis on top of her extensive medical history, it meant

that the infections would likely be harder to fight off since a few of her vital organs were not

working to their full potential.

While I was receiving report on my patient, the nurse stated that the patient was currently

off the unit at dialysis, but was alert and oriented times four, vital signs were stable and the

patient was able to communicate in clear and complete sentences. However, when I was able to

perform my assessment on the patient when she returned to the unit from dialysis, it appeared

that the patient’s status had changed. D.H. appeared to be in some distress and was only alert to

self. D.H. would only look at me when I said her name, but could not verbally communicate

with me. Instead, she repeatedly moaned out loud. The changes in the patient’s status upon return

from the dialysis unit caused for a rapid response to be called.

When I obtained my first set of vital signs on D.H., her blood pressure was 99/46, pulse

was 88, oxygen saturation was 99% on four liters nasal cannula, respirations were 18,

temperature was 97.1 degrees Fahrenheit. The second set of vitals I obtained on D.H. later on in

my shift was a blood pressure of 95/60, pulse of 88, oxygen saturation of 100% on four liters

nasal cannula, respirations of 20, and temperature of 97.5 degrees Fahrenheit. During my care,

the patient was unable to accurately scale her pain level. However, the patient was moaning out

loud and showed facial grimacing as if she may have been in pain, so we were repositioning her

every two hours and the moaning slightly decreased.

Further assessment showed that the patient’s head/face appeared to be normocephalic and

her eyes showed PERRL. I was unable to assess accommodation due to the patient not being

alert enough to follow my commands. D.H.’s hearing appeared to be intact, since she looked at
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me when I said her name out loud. Mucous membranes were pink and moist. The patient did not

have any teeth and normally wears dentures, but she was not wearing them during my

assessment. The patient’s trachea was midline and I was unable to assess the patient’s ability to

swallow due to the decreased level of consciousness. D.H.’s lung sounds were clear and slightly

diminished anteriorly. Breathing was slightly labored and it increased with activity, especially

when we turned the patient to promote comfort. Heart sounds were regular rate and rhythm with

auscultation. Normal S1 and S2 heart sounds were heard, apical pulse was 88 bpm, radial pulses

and posterior tibial pulses were 2+ in strength. Abdomen was soft, nontender and nondistended.

Bowel sounds were active and present in all four quadrants. D.H.’s last bowel movement was on

2/21/21. D.H. had difficulty with urination and intake did not equal output. According to the

patient’s input and output on the chart, it showed that on 2/21/21, D.H. had an input of 797.30mL

and output of 50mL during a 24-hour period. On 2/22/21, it showed that by the end of my shift at

2000 that the patient had an input of 335mL and output of 0mL. The decreased urine output

impacted the plan of care because since the patient was already in end stage renal disease, it

would make it harder for her to be able to produce urine. The patient’s skin was warm,

slightly dry and normal color for ethnicity. The patient’s Braden scale score was a 15, which

means she was at moderate risk for developing skin ulcers. The patient had a stage 1 pressure

ulcer present on her coccyx. The pressure ulcer was reddened and did not blanch. This impacted

the patient’s plan of care because since she already had a pressure ulcer, I wanted to implement

interventions to prevent new pressure ulcers from developing. Skin turgor was non-elastic. I was

unable to assess hand grasps, pushes and pulls, along with pedal pushes and pulls due to the

patient’s decreased level of consciousness. D.H. had 2+ edema in her bilateral upper extremities,

as well as 3+ edema in her bilateral lower extremities.

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I used the above assessment data obtained to formulate a patient specific plan of care.

The patient had a few abnormal findings during my head-to-toe assessment of her. D.H. had

abnormal finding such as disorientation, decreased urine output, peripheral edema to the upper

and lower extremities, slightly low blood pressure, stage 1 pressure ulcer, facial grimacing,

moaning and labored breathing. These findings all played as factors in coming up with

appropriate nursing diagnoses that will be addressed later in this paper.

My patient had labs and diagnostic testing done during her hospital stay. The abnormal

lab values that were on the high end included WBC, BUN and creatinine levels. The patient’s

WBC count was 14.7 x 10^3, which was likely high because the patient had sepsis and a urinary

tract infection (Van Leeuwen and Bladh, 2017). The BUN was 40 and the creatinine was 4.69.

These levels were likely high because the patient was in end stage renal failure and her kidneys

were shutting down (Van Leeuwen and Bladh, 2017). In addition, the patient also had lab values

that were on the low end, which included the hemoglobin, hematocrit and platelet levels. The

hemoglobin level was 8.7 and hematocrit was 27.4%. Both of these levels were low due to the

patient having chronic anemia (Van Leeuwen and Bladh, 2017). The platelet count was 96 x

10^3, which may likely be related to the sepsis (Van Leeuwen and Bladh, 2017). The abnormal

lab values all played a role in coming up with an appropriate plan of care for my patient, such as

the BUN and creatinine levels. These levels are used as indicators for kidney function. Since my

patient is in end stage renal disease, I will mention these in one of the priority care plans that I

used to address the patient’s problem regarding kidney function. The only diagnostic

examination that D.H. had done was a chest x-ray, which showed right basilar atelectasis and

interstitial edema, which meant that her lungs were partially collapsed (Van Leeuwen and Bladh,

2017).
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There were activity and nutrition orders that were placed for this patient to help promote

kidney function and activity tolerance. The patient’s diet order was to follow a Renal and ADA

1800kcal diet. The patient’s activity order was to get out of bed with assistance a few times

daily. Unfortunately, due to D.H.’s change in status, she was not alert enough to take in any

food and she didn’t drink anything during my care. Additionally, the nurses and I did not feel

comfortable getting the patient out of bed due to her unstable condition. The patient’s nutrition

played a role in forming a plan of care because she was not taking in very much in fluids.

Additionally, the patient’s activity level played a role in the plan of care because she was not

getting out of bed, which could have likely caused more harm to her health than good, such as

worsening of pressure ulcers, if proper interventions weren’t put in place.

My patient was on multiple different medications. One of the medications that my patient

was on was Duloxetine (Cymbalta) 60mg/1 capsule PO QAM. This medication is an SNRI

antidepressant, or a serotonin-norepinephrine reuptake inhibitor. It works by inhibiting the

reuptake of serotonin and norepinephrine in the central nervous system to help treat depression

and anxiety (Vallerand, Sanoski, & Quiring, 2019). The patient was receiving this medication

because she had a medical history of anxiety and depression. The second medication my patient

was on was Acetaminophen (Tylenol) 650mg/2 tablets PO TID. Tylenol is an analgesic and an

antipyretic. It works by reducing prostaglandins within the brain (Vallerand, Sanoski, & Quiring,

2019). It was being used by my patient to relieve pain. The third medication my patient was on

was Albuterol-ipratropium (DuoNeb) 3 mL inhalation TID. DuoNeb is a bronchodilator and it

works by blocking the muscarinic receptors of acetylcholine to help relax breathing (Vallerand,

Sanoski, & Quiring, 2019). It was being used by my patient because she was having difficulty

breathing. The fourth medication my patient was taking was Ascorbic acid (Vitamin C) 500mg/1
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tablet PO BID. Ascorbic acid (Vitamin C) is a water-soluble vitamin and works as a replacement

when Vitamin C is deficient within the body to help aid in collagen formation and tissue repair

(Vallerand, Sanoski, & Quiring, 2019). My patient was on this medication because she likely has

a vitamin deficiency in relation to her chronic kidney disease. The fifth medication my patient

was on was cholecalciferol (Vitamin D) 1250mcg/1 capsule PO. This medication is a vitamin D

replacement and it works by facilitating intestinal absorption of calcium to help promote bone

growth and health (Vallerand, Sanoski, & Quiring, 2019). D.H. is taking this medication to treat

her osteoporosis and Vitamin D deficiency. The sixth medication my patient was on was ferrous

sulfate (iron) 325 mg PO BID. This medication is an iron replacement, which works by

replenishing iron within the body and my patient is taking it for chronic anemia (Vallerand,

Sanoski, & Quiring, 2019). The sixth medication my patient was on was insulin lispro

(Humalog), which was a sliding scale. Humalog is a fast-acting insulin and it works within the

body to regulate blood glucose levels (Vallerand, Sanoski, & Quiring, 2019) My patient was on

this medication to treat her Type 2 Diabetes. The seventh medication my patient was on was

pantoprazole (Protonix) 20mg/1 tablet PO BID. This medication is a proton pump inhibitor and it

works by decreasing the amount of acid that the stomach creates (Vallerand, Sanoski, & Quiring,

2019). My patient was on this medication to treat GERD. The eighth medication my patient was

on was piperacillin-tazobactam (Zosyn) 3.375mg/50 mL to run at 12.5mL/hour IV piggy back

every 12 hours. This mediation is a penicillin antibiotic and it works by inhibiting the growth of

infection causing bacteria (Vallerand, Sanoski, & Quiring, 2019). My patient was on it to treat

sepsis and the UTI she had. The final medication that my patient was on was Ativan (lorazepam)

0.25mg/0.13 mL IV push PRN once per day. This medication is a benzodiazepine and it acts on

the brain and central nervous system to produce a calming effect (Vallerand, Sanoski, & Quiring,
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2019). This medication is being used to treat the patient’s depression and anxiety.

We were asked to come up with a care plan for our chosen patient that included four

nursing diagnoses, which correlated with four problems that the patient had. One diagnosis

addresses the patient’s priority nursing problem, one diagnosis addresses the ability to provide

holistic and culturally competent care, one problem addresses a secondary nursing problem and

one diagnosis addresses a knowledge deficit. Then, for each nursing problem, there are five

nursing interventions that were implemented. In addition, short-term and long-term goals were

made for each diagnosis, along with an evaluation of each care plan to determine effectiveness.

My priority nursing diagnosis for D.H. is Ineffective Renal Tissue Perfusion related to

glomerular malfunction as evidenced by increased BUN of 40, increased creatinine of 4.69,

decreased urine output (<30mL/hr), peripheral edema (2+ bilateral upper extremities and 3+ in

bilateral lower extremities), decrease in blood pressure (admitting blood pressure was

123/61mmHg and most current blood pressure was 99/46mmHg), and patient is on dialysis. The

short-term goal I created was that the patient would maintain a systolic blood pressure of greater

than 90 mmHg by the end of my shift at 2000 on 2/22/21. The long-term goal for this patient was

that renal tissue perfusion would show an improvement as evidenced by decrease in peripheral

edema in upper and lower extremities, decrease BUN level, decrease creatinine level by follow

up appointment in two weeks. The first intervention was to assess the vital signs every four hours

and as needed. This would provide a guideline as to if the blood was circulating adequately

(Gulanick and Myers, 2017). The second intervention was to assist the patient with oral intake

every 1-2 hours. Since the patient was not alert enough to do this on her own, she would need

assistance with this to help promote hydration (Gulanick and Myers, 2017). The third

intervention was to provide oral care every two hours. By providing oral frequently, this will
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help promote an interest in oral fluid intake to promote hydration (Gulanick and Myers, 2017).

The fourth intervention was to reposition the patient and elevate arms/legs on pillows every two

hours and as needed. Repositioning the patient will help prevent fluid accumulation in dependent

areas. Elevating the edematous arms and legs will help increase venous return, which may help

with decreasing edema (Gulanick and Myers, 2017). The fifth intervention was to teach the

patient the importance of adequate fluid intake as needed when the patient is alert and oriented.

Adequate fluid intake is important to maintain hydration and also helps with the excretion of

urine (Gulanick and Myers, 2017). During my evaluation of this care plan, I felt that the

interventions helped work towards the goals I created. Since my patient was in end stage renal

failure, it would definitely be harder to reach the long-term goal of improved renal tissue

perfusion, since the kidney function would be irreversible at this point. However, the patient’s

systolic blood pressure was maintained above 90mmHg, as evidenced by a blood pressure 95/60

that I obtained prior to the end of my shift.

The second nursing diagnosis for D.H. is Impaired Skin Integrity related to immobility as

evidenced by stage 1 pressure ulcer on coccyx that is reddened and non-blanchable. The short-

term goal was to prevent additional ulcers from occurring by discharge. The long-term goal was

that the patient’s skin would return to normal structure and function within one month. The first

intervention would be to assess the skin over any bony prominences, such as the coccyx, heels,

back of head, elbows, etc. every four hours. Since these areas are more prone to pressure ulcers,

it would be important to assess these areas frequently to ensure pressure sores are not developing

(Vera, 2020). The second intervention would be to reposition the patient every two hours and

as needed. Repositioning the patient frequently will help decrease the risk of pressure ulcers

(Vera, 2020). The third intervention would be to utilize pillows and foam wedges under bony
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prominences every two hours. Utilizing pillows and foam wedges under bony prominences will

help reduce shearing against the skin (Vera, 2020). The fourth intervention would be to apply a

Duoderm dressing to the coccyx area and other areas as needed. A Duoderm dressing will help

prevent shearing and friction to the pressure ulcer prone areas (Vera, 2020). During my

evaluation of this care plan, I feel that these interventions were appropriate to work towards the

patient centered goals. The patient did not show any signs of other pressure ulcers developing

and was repositioned every two hours. Pillows and foam wedges were utilized to help prevent

the development of other pressure ulcers as well. I felt that this was overall an appropriate care

plan for this patient because during my research, I learned that decreased mobility and edema can

impair tissue perfusion and increase the risk of pressure ulcers. This is why it is so important to

assess the condition of the patient’s skin every shift and utilize strategies to aid in preventing

pressure ulcers within the care plan (Thornburg and Gray-Vickrey, 2016). I could improve this

care plan by repositioning the patient more frequently, or find other nonpharmacological ways to

prevent pressure ulcers from developing.

The third nursing diagnosis I would use for this pateint would be acute pain related to

immobility as evidenced by facial grimaces, moaning out loud, breathing becomes more

labored during activity (repositioning). The short-term goal would be that the patient will show

signs of comfort as evidenced by decreased moaning and non-labored breathing patterns by the

end of the shift. The long-term goal would be that the patient will be able to report pain level

verbally by discharge. The first intervention would be to assess the patient for signs/symptoms of

pain, such as facial grimaces and increased breathing pattern every hour. Assessing the patient

allows the nurse to recognize whether the patient is exhibiting signs of pain (Vera, 2020). The

second intervention would be to reposition the pateint every two hours. Repositioning the patient
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may help decrease pain/discomfort (Vera, 2020). The third intervention would be to promote a

quiet environment during the entire shift. This will help promote comfort and rest for the client

(Vera, 2020). The fourth intervention would be to administer Tylenol three times a day as

prescribed. Tylenol is an analgesic and will help alleviate pain and promote comfort (Vera,

2020). The fifth intervention would be to teach the patient nonpharmacological ways to decrease

pain as needed when patient is alert and oriented times four. Teaching the patient

nonpharmacological ways to relieve pain, such as deep breathing and relaxation techniques may

help promote comfort without using medications (Vera, 2020). During my evaluation of this care

plan, I feel that these interventions were appropriate to implement to meet the goals I set for this

patient. I assessed the patient frequently for facial grimaces, moaning and labored breathing

patterns. It appeared that once we began repositioning the patient every two hours, she became

more relaxed and was able to rest. One thing that I would add to improve this care plan would be

to assess the patient’s pain using the Wong-Baker FACES pain scale, which may have given me

a more accurate description of the patient’s level of pain.

The fourth nursing diagnosis I would use for this patient would be disturbed thought

process related to infection within the urinary tract as evidenced by only alert to self and

disoriented to place, time, situation. The short-term goal would be that the patient shows increase

in mental status as evidenced by alertness to person, place, time and situation by discharge. The

long-term goal would be that the patient would be able to verbalize ways to prevent infection,

such as UTI by follow up appointment in two weeks. The first intervention would be to

assess the patient’s neurological status every 2 hours. Assessing the patient’s neurological status

will help determine if the treatment for the infection is being effective and if the client’s status is

improving (Vera, 2020). The second intervention would be to reorient the patient to place, time
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and situation as needed. Reorienting the patient may help improve their neurological status by

helping them recognize reality (Vera, 2020). The third intervention would be to monitor labs

such as BUN and creatinine levels once per shift. When these levels are corrected and closer to

normal, they may help improve the patient’s mental status (Vera, 2020). The fourth intervention

would be to administer Zosyn 12.5mL/hour IV piggy back every 12hours. Administering an

antibiotic, such as Zosyn will help fight the UTI and sepsis, which may help improve the

patient’s mental status (Vera, 2020). The fifth intervention would be to teach the patient about

the infections and ways to prevent them when the patient is alert and oriented times four.

Teaching the patient about the UTI and sepsis, along with how to prevent infections may help

prevent future infections from occurring (Vera, 2020). During my evaluation of this care plan, I

felt that these interventions would be appropriate to help meet the patient centered goals.

However, the patient’s mental status did not improve by the end of my care. There may have

been more appropriate interventions that I could have implemented, such as attempting to

reorient the patient more frequently.

Lastly, we were asked to go the Healthy People website and review the Healthy People

2030 goals. Then, we were asked to relate the goals and objectives to our chosen patient. There

are five goals included in Healthy People 2030. The first goal is to “attain healthy, thriving lives

and well-being free of preventable disease, disability, injury and premature death (“Healthy

People 2030,” n.d.). The second goal is to “eliminate health disparities, achieve health equity,

and attain health literacy to improve the health and well-being of all (“Healthy People 2030,”

n.d.). The third goal is to “create social, physical and economic environments that promote

attaining the full potential for health and well-being for all (“Healthy People 2030,” n.d.). The

fourth goal is to “promote healthy development, healthy behaviors and well-being across all life
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stages (“Healthy People 2030,” n.d.). The fifth and final goal is to “engage leadership, key

constituents, and the public across multiple sectors to take action and design policies that

improve the health and well-being of all (“Healthy People 2030,” n.d.).

I can tie the goals from Healthy People 2030 into the care that I provided to my chosen

patient. I felt that I worked towards goal one by repositioning my patient every two hours to help

aid in prevention of developing pressure ulcers. In addition, I also administered the antibiotic

Zosyn to help prevent the infection from worsening. I worked towards goal two by ensuring I

was providing safe and adequate care to my patient to attempt to promote their overall health and

well-being. I worked towards goal three by promoting a safe, quiet environment for patient and

doing what I could to make sure she was comfortable, such as dimming the lights and

repositioning her every two hours. I worked towards goal four by administering the prescribed

medications to help promote the patient’s overall health through the use of antibiotics to fight off

the infection and analgesics to help minimize pain. I attempted to work towards the last goal by

following infection control policy by ensuring that I sanitized my hands upon entering and

exiting my patients’ room, along with wearing my mask and safety goggles.

In conclusion, I really learned a lot from doing this nursing process paper. I learned how

to analyze demographics, medical history, subjective/objective data, labs, diagnostic

examinations, activity and nutrition orders and medications that my patient was taking to come

up with an appropriate plan of care. I also learned about the Healthy People 2030 goals and

found it interesting to tie those goals into the care that I provided to my patient. Overall, I really

enjoyed this assignment. It really helped me improve on my care planning and critical thinking

skills. I am sure this project will help me come up with appropriate and effective care plans in

the future.
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Reference

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions & outcomes.

St. Louis: Elsevier.

Healthy people 2030 framework. (n.d.). Retrieved March 14, 2021, from

https://health.gov/healthypeople/about/healthy-people-2030-framework

Thornburg, B., MSN, RN, & Gray-Vickrey, P., DNS, RN. (2016, June). Acute kidney injury:

Limiting the damage: Nursing2021. Retrieved from

https://journals.lww.com/nursing/fulltext/2016/06000/acute_kidney_injury__limiting_the_

damage.7.aspx

Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Davis's drug guide for nurses.

Philadelphia, PA: F. A. Davis Company.

Van Leeuwen, A. M., & Bladh, M. L. (2017). Handbook of laboratory and diagnostic tests with

nursing implications. F A Davis.

Vera, M. (2020, August 14). 17 chronic renal Failure nursing care plans. Retrieved from

https://nurseslabs.com/6-chronic-renal-failure-nursing-care-plans/3/