In this assignment, you will cluster the assessment data provided and, utilizing the care plan form, you will write a few nursing diagnoses for this patient, complete with outcomes, interventions, and evaluation examples.
Tasks:
Review the following scenario and admission data:
Ms. Jones is a patient at the gynecological unit where you work. She is coming in for a hysterectomy (removal of the uterus).
37 y/o woman, unmarried hairdresser
Allergic to penicillin
Continual vaginal bleeding for the past 6 months
States mother had cervical cancer
States has never been pregnant
Not concerned about the effect of hysterectomy on sexuality
States has asthma
Smokes 1/2 pack per day for 16 years
Light social drinker
Hospitalized at age 14 for appendectomy
States vision is 20/20 with glasses
Skin warm and dry/Good skin turgor
Oriented to time, place, and person
Takes iron supplements/bulk-forming laxative
Bulk-forming laxative daily
Frequent headaches, takes ASA (aspirin) to relieve
One formed stool per day; occasional constipation
Urinates 5-6 times per day, "No difficulty"
Manages all activities of daily living (ADLs)
Drinks lots of water
3 meals a day, snacks often
"I sleep a lot" when under stress.
Temp 100 degrees F
BP 120/80 mmHg
Weight - 130 pounds / Height - 5'5"
Lungs CTA (Clear to auscultation)
Full range of motion (ROM) of the neck
Blood sugar 124 mg/dL
Hemoglobin 9.5
Chest x-ray (CXR) within normal limits (WNL)
Wants to see the hospital chaplain before surgery
Create a care plan with appropriate nursing diagnoses, outcomes, and interventions.
For the evaluations, come up with possible outcomes and how you would use those outcomes to evaluate if goals were met, partially met, or unmet.