Question

Create a care plan with at least three nursing diagnosis based on the scenario. One diagnosis must be related to pathophysiology and three must be related to environment, situation, psycho-social or maturity taking into account culture.

Nursing Diagnosis:

Goal#1

Nursing interventions (list 4)

Goal #2

Nursing interventions (list 4)

As a staff nurse in an acute care facility on the surgical inpatient unit, you receive an admission from the emergency room (ER). The ER nurse calls report to you prior to your patient's arrival to your floor and tells you the patient, Faurah, is 46 years old who presented to the ER via public bus with severe abdominal pain in the right upper quadrant, nausea and vomiting since early this morning. She is accompanied by her 12 year old son. Faurah and her son are political refugees from Liberia who have been in the U.S. for one month. Faurah has an obvious deformity in her left arm resulting from a fracture during an interrogation in her home country where the fracture was never medically treated. Faurah's son was in a school in Liberia in which he was taught English in addition to his native language and is interpreting between Faurah and the medical professionals in the ER. Faurah's husband has not been able to join his family in the U.S.. Faurah and her son have been staying in local housing provided by County Social Services. An IV was started in the ER to administer pain medication and an ultrasound was completed. Faurah has many gall stones and a surgical consult has been made but the surgeon has not been able to see Faurah yet. The ER needs the bed so Faurah is being transferred to the surgical unit to wait for the consult to be completed. The ER physician writes orders for NPO status, LR @ 125 ml/hr, Morphine 1-2 mg every 1 hour for pain, and bathroom privleges. Your patient arrives to the surgical unit, crying and scared. Her 12 year old son is at the bedside. as the primary nurse, being culturally considerate, what are your primary nursing diagnoses?

Answer 1

• Get your template out (the NRSNG Care Plan Template might help)
• Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
• Create your nursing diagnosisUse your S’s and O’s to place your subjective and objective data
• Write out your interventions and outcomes/evaluation