21 Apr Case Study A patient is being treated with combination antiviral drugs for HIV and locally active antiviral drugs that include zidovudine and acyclovir. The
Case Study
A patient is being treated with combination antiviral drugs for HIV and locally active antiviral drugs that include zidovudine and acyclovir. The nursing instructor and student are preparing a 5-minute presentation on antiviral agents for clinical preconference. The nursing student has to assist with preparing medication information about the antiviral medications that are being administered to the client. How would the nursing student assist with preparing the information for the presentation?
Assignment Instructions
Please complete the following case study analysis utilizing the following:
The Nursing Process:
A – Assessment
D – Diagnosis (Use NANDA nursing diagnoses)
P – Plan (Outcome with a specific short and long term goal)
I – Implementation
E – Evaluation
Additional Information to include if applicable: Medication (class, mechanism of action, dosage [standard if not provided], indication, side effects, contraindications)
See note attachment.
Requirements
- Submit your answer as a word document or by typing your answer in the submission box below.
Nursing Process Notes
Acronym
A: Assessment
D: Diagnosis
P: Planning
I: Implementation
E: Evaluation
Background
In 1958, Ida Jean Orlando began the nursing process that guides nursing care and practice in the present day.
· The nursing process is a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition.
· Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care
Purpose
The nursing process functions as a systematic guide to client-centered care with five sequential steps. These steps are assessment, diagnosis, planning, implementation, and evaluation.
Step 1: Assessment
Assessment involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data in and assist in assessment.
Critical thinking skills are essential to assessment, therefore the need for concept-based curriculum changes.
Step 2: Diagnosis:
The preparation of a nursing diagnosis by utilizing clinical judgment assists in the planning and implementation of patient care.
· The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses.
· A nursing diagnosis, according to NANDA, is defined as a clinical judgment in relation to responses to actual or potential health problems and situations on the part of the patient, family or community.
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the foundation for physical and emotional health (Examples of nursing diagnoses are accessible on the following link: https://ar.israa .edu.ps/ uploads/documents/2020/02/4gcM0.pdf
Maslow's Hierarchy of Needs
· Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC's), sleep, sex, shelter, and exercise.
· Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease).
· Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, sexual intimacy.
· Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one's physical appearance or body habitus.
· Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one's maximum potential.
Step 3 Planning
· The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines.
· These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
· Care plans, Care maps, and case studies provide a course of direction for personalized care tailored to an individual's unique needs.
· Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.
Goals should be:
1. Specific
2. Measurable or Meaningful
3. Attainable or Action-Oriented
4. Realistic or Results-Oriented
5. Timely or Time-Oriented
The acronym SMART will assist in the remembering goals
Step 4: Implementation
Implementation is the step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols and EDP standards.
Step 5: Evaluation
This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
,
Running head: NURSING CARE FOR A PATIENT SCENARIO
Case Study: Nursing Care for Ms. Jones
Name
Academic Institution
NURSING CARE FOR A PATIENT SCENARIO 2
Case Study: Nursing Care for Mrs. Jones
Ms. Jones: Nursing Case Study
Assessment(A)
Ms. Jones has come to the hospital with the primary complaint of blurred vision which is not
amenable to relief by wearing glasses. Her disclosure of being hypertensive as well as diabetic serves to
induce the immediate suspicion of diabetic retinopathy. Ms. Jones is currently taking antihypertensive
medication that include the diuretic, Lasix, an ACE inhibitor Captopril, and the oral hypoglycemic drug
Glucotrol. Ms. Jones states she is a middle aged, 55 year old female, obese, with a family history of early
deaths of her father and brother due to heart attack are suggestive of genetic predisposition to
hypertension and obesity. She has high blood pressure and blood glucose levels upon presentation at the
clinic are suggestive of the chronic nature of her condition. She states that her mother’s diabetic status
also suggests an inherited link for diabetes mellitus. Important healthcare findings about Ms. Jones can be
listed as follows:
Subjective data. Ms. Jones is a, 55 year old female, with a family history of premature deaths of her
father and brother due to heart attack and that her mother’s had diabetic mellitus with a complaint of blurred
vision without relief with the use of glasses.
Objective data. Ms. Jones is 5ft.’ 2in’ tall hypertensive, diabetic female with obvious obesity
indicated by her currently observable 170 lbs. of body weight. Her history also reveals a positive diagnosis
of hypertension as well as type 2 diabetes mellitus in the past. Ms. Jones is already on an antihypertensive
regimen which includes the diuretic, Lasix, The ACE inhibitor Captopril in addition to the oral
hypoglycemic drug Glucotrol for controlling blood sugar.
Diagnosis (D)/Nursing Diagnosis (Berman et al. 2017)
The primary nursing diagnosis for Ms. Jones is that of “risk for disturbed sensory
perception” due to the immediate vision impairment from present and unstable diabetic state,
which has persisted (North American Nursing Diagnosis Association [NANDA].2017). History
NURSING CARE FOR A PATIENT SCENARIO 3
of long standing hypertension, diabetes and her obese condition are suggestive of this diagnosis.
Further confirmation can be obtained after evaluating the results obtained from retinal
examination and other eye tests if recommended. The major changes in type 2 diabetes are the
development of erratic blood glucose varying from hypo to hyperglycemia, increased
predisposition for infections, peripheral nephropathy/retinopathy sometimes leading to blurred
vision as well as blindness (Berman et al. 2017)
Plan (P)
Mrs., Jones needs to be put on a diet regimen which includes only the recommended
calorific intake and her diabetes needs to be controlled in order to keep her plasma sugar levels
at an optimum level of 80-120 mg/dL(Berman et al. 2017). If any abnormal changes in her
retina are detected, it needs an immediate surgical intervention to prevent further damage. She
needs to follow a more controlled lifestyle after the intervention which should include
appropriate control of diet, incorporation of a light exercise regimen to bring down her weight
and religious intake of antihypertensive and anti diabetic drugs with nursing education and
support.
Long-term goals/desired outcomes. Within the duration of care, Mrs. Jones will be able to:
• Demonstrate interest/behaviors and lifestyle changes to improve her well-being,
glycemic control, nutrition, hypertension, medication regimen and compliance, and
visual impairment.
Implementation/Interventions (I) (Berman et al. 2017)
Nursing care implementation and interventions include:
• Consult a dietician or nutritionist to cater for the client’s nutritional needs.
• Assessing and educating Ms. Jones concerning her diabetic and hypertensive medication
regiment and compliance.
• Assessment of the eye for any abnormal lesions in the retina suggestive of diabetic
NURSING CARE FOR A PATIENT SCENARIO 4
retinopathy and further examination, such as angiography if recommended by her
practitioner.
• Reviewing the comprehensive metabolic panel and fasting plasma glucose level and a
glucose tolerance test to further assess hypertensive and diabetic states.
• Evaluation of her diet habits for investigating the role of high calorie foods.
• Education, referrals, and option for health lifestyle practices to address her obesity and is
risk and health factors and complexities also involving her present diagnosis of diabetes
mellitus.
Evaluation (E)
Ms. Jones will require expert nursing concerning diabetic, hypertensive, and medication
education, as well as nutritional and psychological counseling to ensure compliance with the
health care recommendations and referrals after discharge from the hospital. She will also need
to visit the medical facility periodically for her health assessment to sustain her plan of care and
its effectiveness.
NURSING CARE FOR A PATIENT SCENARIO 5
References
Berman, A., Snyder, S. J., Kozier, B. & Erb, G. (2017). Kozier & Erb’s fundamentals of nursing:
Concepts, process, and practice (11th ed., p. 905 & pp. 1296-1298). Upper Saddle River,
New Jersey: Pearson Prentice Hall.
North American Nursing Diagnosis Association (NANDA) International Staff. (2017). Nursing
diagnoses: Definitions and classification, 2015-17. Hoboken: John Wiley & Sons,
Incorporated.
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