Reference no: EM133670261

Assignment:

"Your patient Cyril Smith is a 72-year-old man who is 2-days post op following a partial colectomy and formation of a colostomy following a diagnosis of bowel cancer. His surgery was uneventful, and he was stable throughout. Last night (Day 1) Mr. Smith required x2 fluid challenges of 300ml each following a hypotensive episode and his IV rate for NaCl was increased from 84 ml/hr to 125 ml/hr. Co-morbidities Diabetes Type 2 (diet controlled) Osteoarthritis (Mr. Smith takes OTC NSAIDs, ibuprofen and paracetamol PRN) COPD (Mr. Smith uses a salbutamol inhaler PRN). Observations Temperature = 37 degrees Celsius PR = 121 bpm (full & bounding) RR = 32 bpm BP = 184/95 mmHg O2 Sats 90% (nasal prongs 2L/min) Hourly urine output 15-30 ml/hour (IDC in situ) BGL = 6.9 mmol/L Pathology Sodium = 128mmol/L Potassium = 3.3 mmol/L Urea = 2.9mmol/L Creatinine = 400 μmol/L Wound - dry dressing and is intact Bellovac in situ and has drained 300ml since yesterday Drainage bag over stoma - no drainage Medications He has a PCA (Patient Controlled Analgesia) pump. On the PCA chart a lockout period of 10 minutes and a dose of 1mg/ml is documented Enoxaparin sodium 40mg SCI Metronidazole 500mg and IV and cephalothin 2g IV You enter the room at 1500 hours with your buddy RN Helen and observe the following: there was a vedio in which the patient is having headache , taking deep breaths and spitting transparent fluids from mouth which is not vomit""

1. Identify ONE (1) actual nursing diagnosis (Hypovolemia or Hypervolemia) and TWO (2) risk/potential nursing diagnoses.

--Nursing Diagnosis" ?related to "XXX" ?as evidenced by "S & S" ?Example--Difficulty swallowing/Dysphagia related to side effects of radiation therapy as evidenced by patient gagging and coughing when eating and drinking

2. For each nursing diagnosis identify an appropriate and person-centred goal of care (each goal is to be SMART (specific, measurable, achievable, realistic, and timely). The SMART goal should directly relate to your nursing diagnosis.

3. For each actual nursing diagnosis describe three appropriate nursing actions to address the patient's problem. Note: Referral to a member of the interprofessional team may be an appropriate nursing action in some situations. Nursing actions can include actions that a Doctor would order - however you need to make sure you state this e.g. administer X type of medication as per MO order

4. For each risk nursing diagnosis describe three appropriate nursing actions to prevent the patient problem from occurring.

5. Discuss a clear rationale for each nursing action. (What is a rationale? This is the WHY you are doing something - therefore this needs to come from the evidence)

6. Explain how you would determine the effectiveness of your nursing actions. Outcome measures must be specific, timely, observable and/or measurable. How do we evaluate & why?