8724104-Nursing-Care-Plan-7-knowledge-Deficit - Case...

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Case Scenario #8 Ambulatory Patient Care Scenario Instructions: For this case scenario you will develop a nursing care plan using the Standardized Nursing Languages (SNL) of NANDA , NOC & NIC . You will be completing the blank telephone encounter form that accompanies scenario. Mrs. Carter is a 56 y.o. female, who was seen five days ago in your surgical clinic by Dr. Such&so. Mrs. Carter was discharged from the hospital eleven days ago following surgical removal of a benign abdominal cyst. The patient has telephoned the clinic complaining of post-operative problems, specifically with her abdominal incision. In the last twenty-four to thirty-six hours, Mrs. Carter has noticed her incision is mildly though continuously tender to touch, & appears slightly reddened & swollen. She denies any drainage. Mrs. Carter does note that she’s feeling ”run down” & “washed out,” more so than any time since her operation; she had anticipated being recovered from her surgery by now, & fully returned to her prior activity level. She periodically feels “warm” & flushed, but hasn’t checked her temperature because she’s unsure how. Mrs. Carter denies any nausea or vomiting, diarrhea or constipation since her post-operative visit. Her past medical history is non-contributory; she has no known (medicinal) allergies. Currently, Mrs. Carter’s medications consist of Tylenol on an as-needed basis. She has taken Tylenol four times in the last twenty-four hours, for incisional tenderness. Mrs. Carter notes that she was instructed, at her post-operative visit, that dressing the incision was no longer necessary. She also states she was instructed that she could now resume her usual hygiene practices, & has taken a tub bath twice since her last clinic visit. Functional Health Patterns Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can help direct the choice of Nursing Diagnoses. The eleven functional health patterns are: Health Perception–Health Management Cognitive–Perceptual Nutritional-metabolic Elimination Activity-Exercise Sleep/Rest Self-Perception/Self-Concept Role/Relationship Coping/Stress/Tolerance Sexuality/Reproductive Value/Belief The Functional Health Patterns that are relevant for Mrs. Carter, listed in order of importance, are: Health Perception–Health Management Cognitive–Perceptual Activity-Exercise Relevant information should be recorded in Assessment , Past Medical History & Current Medications on the Patient Telephone Encounter form.
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Step 1. Choosing the Nursing Diagnosis (es) (NANDA) The following nursing diagnoses are appropriate for this patient. In practice, you may select additional nursing diagnoses. Nursing Diagnosis: Infection, Risk for Defining Characteristics: Patient complains of incision is tender to touch, & appears reddened & swollen. She denies any drainage.
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This note was uploaded on 02/10/2010 for the course ADN 105 taught by Professor Aaa during the Spring '07 term at 東京大学.

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8724104-Nursing-Care-Plan-7-knowledge-Deficit - Case...

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