NURSING PROCESS

1
NURSING PROCESS

• Diagnosis

2
Identify the correctly written diagnoses

• High risk for injury related to unstable gait and
  dizziness
• Anger related to death of sister
• Disuse syndrome related to immobility
• Stress incontinence related to involuntary loss
  of urine with coughing

3
Identify the phase of the nursing process

• While walking Mrs. Woolsey to the bathroom, she
  complains of dizziness
• Ask her if the dizziness is related to an
  activity
• Take her blood pressure in lying and standing
  positions
• Determine what interventions will reduce her
  dizzines

4
Identification (contd)

• Later, in the day, check with her if additional
  episodes have occurred
• Teach her to change her position slowly
• Formulate the nursing diagnosis High Risk for
  Injury related tovertigo secondary to postural
  hypotension

5
Identification (contd)

• Mr. Todd has not been drinking enough fluids. He
  drank 600 mL from 7 a.m. to 7 p.m. You
• Asking him why he is drinking so little
• Formulate the diagnosis Fluid Volume Deficit
  related to fatigue and decreased desire to drink

6
Identification (contd)

• Establish a fluid intake goal with Mr. Todd for
  each 12 hr. shift
• The next day, review his 24 hr. fluid intake,
  output, and specific gravity
• Teach him how to record intake and output
• Explain why inadequate hydration is a problem

7
EVALUATION ACTIVITY

• Phase of the nursing process

8
Learning exercise

• Mrs. Vernon is unconscious after a cerebral
  vascular accident (stroke). Presently she has no
  evidence of pressure ulcers but is at high for
  developing pressure ulcers.
• Which of the following goals is the most helpful
  to evaluate this nursing diagnosis?

9
Learning exercise (contd)

• Will be turned at least every 2 hrs.
• Will be free of incontinence
• Will continue to demonstrate skin free of
  pressure ulcers