PRN0098C Chapter Notes -Nursing Diagnosis, Orthopnea, Clinical Pathway

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alexandrasearle

27 Oct 2022

School

SJRSC, St Johns River Community College

Department

Nursing And Allied Health

Course

PRN0098C

Professor

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Document Summary

Chapter 4: the nursing process - critical thinking and decision making. The nursing process is a decision making framework used by all nurses to determine the needs of their patients and to decide how to care for them. A care plan is a documented plan for giving patient care and includes the hcps orders, nursing diagnoses, and nursing orders. Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action - used by nurses during during decision making. Nurses who use critical thinking avoid jumping to conclusions about patients or patient care, and avoid making decisions based on assumptions - they validate (ensure the correctness of) the information they obtain. Think purposefully, using reasoning and logical thought, to determine whether your actions are appropriate for the optimal care of your patient. Assessment is the gathering of information through signs and symptoms, patient history, and both subjective and objective findings.

Related Questions

1. The nurse working in a long-term care facility incorporates a focused assessment of
the immune system for all newly admitted patients over the age of 65. Older adults

are more likely to develop problems related to immune function than are middle-
aged people. The focused immune assessment includes a systemic approach based

on age-related changes in immunologic function. (Learning Objective 4)
a. What changes in the immune system in the older adult increase the incidence of
infection and cancer in this population?
b. Explain why older adults may have decreased inflammatory responses.
c. Why are older adults at increased risk of gastroenteritis and diarrhea secondary
to proliferation of intestinal organisms?

2. The nurse educator for an oncology unit is preparing an in-service presentation for
new nurses about the care of patients with immunodeficiencies. Patients with cancer
who are receiving chemotherapy, as well as those with bone marrow transplants, are
immunocompromised and require special attention to assess for signs of infection.
The nurse educator focuses on special care needs of this patient population.
a. What is the rationale for assessing the pulse and respiratory rates for 1 full
minute in a patient with immunodeficiency?
b. What special precautions about dietary restrictions and food preparation should
be included in the teaching for a patient with immunodeficiency?
c. What nursing actions should be implemented to decrease the risk of infection in
the patient with immunodeficiency?
3. Molly Baker, a 22-year-old patient, presents to the clinic with the diagnosis of
allergic rhinitis. She states that she develops paroxysmal sneezing, clear nasal
drainage and congestion, watery, red eyes, and nasal itching from the late spring
until the first frost in the fall. She states that she has a dry cough and voice
hoarseness. She complains of feeling extremely tired, unable to sleep at night, and
having difficulty concentrating on her collegiate course work.
a. What further assessment should the nurse provide?

Ellie Long, a 55-year-old patient, presents to the pain clinic with the diagnosis of
fibromyalgia syndrome. The nurse at the clinic obtains a history and physical
assessment of the patient. (Learning Objective 2)
a. On what areas should the nurse concentrate when interviewing the patient
during the history process?
b. On what areas should the nurse concentrate when assessing the patient?
c. What diagnostic tests are used with fibromyalgia syndrome?

goldworm200

#10 A patient is admitted as a hospital inpatient with a diagnosis of possible myocardial infarction. During admission, the patient falls while walking and fractures his left hip. Which present on admission (POA) indicator applies to the left hip fracture diagnosis?

a. Y (present at the time of inpatient admission)

b. N (not present at the time of inpatient admission)

c. U (documentation is insufficient to determine if condition is present on admission)

d. W (provider is unable to clinically determine whether condition was present on admission or not)

StewartRenee

Do any of these instructional notes apply to this scenario?

EXCLUDES: Lung removal with bronchoplasty (32501)

Code also decortication (32320)

Code also excision of chest wall tumor, when performed (21601-21603)

Documentation:

PREOPERATIVE DIAGNOSIS: Mass of lung

POSTOPERATIVE DIAGNOSIS: Carcinoma of the right lung

OPERATION PERFORMED: Bronchoscopy and right upper lobectomy

The patient was brought into the operating room, and after the

administration of anesthesia, the patient was prepped and draped in the usual sterile fashion. The patient was placed in the left lateral decubitus

position. A thoracotomy incision was made. This exposed the chest

muscles, which were incised and retracted. The fourth and fifth ribs were

visualized and transected to allow entrance to the chest. A tumor mass was

noted. This mass measured 7.0 cm in diameter, involving the right lung

upper lobe. The mass was excised in its entirety, and a biopsy of the mass

was taken and sent for frozen section. The frozen section revealed

squamous cell carcinoma. Nodes were then dissected around the pulmonary

artery and the trachea. The nodes were sent for frozen section. The nodes

were identified as negative per pathology. Saline was irrigated into the

chest. It was noted that the liver and diaphragm appeared to be normal with

no lesions seen. After verification that the sponge count was correct, chest

tubes were placed for drainage. The surgical wound was closed in layers

with chromic catgut and nylon. The patient tolerated this portion of the

procedure well.

The patient was then placed in the supine position for the bronchoscopy.

The patient was still under anesthesia. A flexible fiberoptic bronchoscope

was inserted. Patient bronchi were noted bilaterally. The scope was

withdrawn. The patient was awakened and sent to the recovery area in

stable condition.

a. Yes

b. No

StewartRenee

PRN0098C Chapter Notes -Nursing Diagnosis, Orthopnea, Clinical Pathway

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