Complete the nursing process worksheet based on the patient
Complete the nursing process worksheet based on the patient below…. Complete the nursing process worksheet based on the patient below. Must be NANDA nursing diagnosis David Nelson is a 16-year-old young man who was admitted to emergency room complaining of difficulty breathing. His vital signs were recorded as BP 95/55, P135/min, Respiratory Rate 26/min, shallow & irregular respirations & oxygen saturation 89% on room air.He was ‘kicked in the right side of his chest’ and is experiencing pain on inspiration. His pain level is 10/10 with increasing difficulty breathing. Chest X-ray revealed a right-sided hemopneumothorax with two rib fractures.Mr. Nelson has a chest drain with under water seal drain inserted under local anesthetic. His condition improves and he is admitted under your care for observation and pain control. Mr. Nelson wants to see his parent. David states “I do not want to see my father as he was abusive toward my mother.”Two police officers arrive at the Emergency Department requesting to interview Mr. Nelson regarding an earlier incident that occurred earlier. History of present illness: Pathophysiology if admitting diagnosis- Must include Pathophysiology, signs & symptoms, risk factors, complications Priority Nursing Problem (2) must be prioritized problem using three part statement (based on abnormal assesment findings) Priority problem -> Related To: Etiology (cause)-> As evidence by: signs and symptoms form assesment. Problem #1 Problem #2 Nursing Risk for Priority prolem (1)- must be priorized problem using three part statement (based on assessment findings) “Risk for…” Problem -> Rekated to: Etiology (cause) Risk for problem #1 Planning/ Patient Goals: 1 for each nursing priority problem (3 total)Must be SMART and start each with Pt. will..” Problem #1 Goal Problem #2 Goal Risk for Problem #1 Goal Implementation- specific nurssing interventions that were performed during your shift (Must have 3 per priority problem)Interventions for priority Problem #1 1.Rationale 2.Rationale 3.Rationale Interventions for Priority Problem #21.Rationale 2.Rationale 3.Rationale Interventions for Priority Risk for Problme #1 1.Rationale 2.Rationale 3.Rationale Evaluation- What was the outcome? Goal met | Goal not met | Goal partially met and how to revise| recommendMust have 1 evaluation per goal. 1.2.3. Health Science Science Nursing NURS 101
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