Question

Okay here is my assignment. 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).

I have attached my Nursing concept map with my diagnosis, goals and interventions. Please review and adjust. Also I could not find a second goal for Risk for deficient fluid volume. I have been working on this for HOURS. Any help is appreciated. Please do not refer me to more websites, I have been to them all!

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?

Cholecystitis

Nursing Diagnosis:

IMPAIRED VERBAL COMMUNICATION related to cultural difference (language barrier) as evidenced by an inability to speak the dominant language of culture

Goal #1: Patient uses form of communication to get needs met and to relate effectively with people and her environment.

Nursing Interventions (one must be education intervention):

1.Provide translator/interpreter

2. Clarify your understanding of the patient’s communication with the     patient or an interpreter

3. Provide alternative means of communication when interpreter not available (phone contact)

4. Ask simple yes or no questions

Goal #2 To assist patient to establish a means of communication to express needs, wants, ideas, and questions

Nursing Interventions (one must be education intervention):

1. Maintain eye contact, preferably at client’s level. Be aware of cultural factors that may preclude eye contact

2. Validate meaning of nonverbal communication; do not make assumptions, because they may be wrong. Be honest; if you do not understand, seek assistance from others.

3. Anticipate needs until effective communication is reestablished.

4. Determine ability to read/write.

Nursing Diagnosis:

Fear related to knowledge deficit evidenced by identification of fearful feelings (crying).

Goal #1: Patient identifies, verbalizes, and demonstrates coping behaviors that reduce own fear.

Nursing Interventions (one must be education intervention):

1. Provide accurate information if irrational fears based on incorrect information are present.

2. Familiarize the patient with the surrounding as necessary.

3. Be with the patient to promote safety especially during frightening procedures or treatment.

4. Maintain a relaxed and accepting demeanor while communicating with the patient.

Goal #2: Patient verbalizes known fears.

Nursing Interventions (one must be education intervention):

1. Use simple language and easy to understand statements regarding diagnostic procedures.

2. Support the patient in recognizing strategies used in the past to deal with fearful situations.

3. Tell patient that fear is a normal and appropriate response to circumstances in which pain, danger, or loss of control is anticipated or felt.

4. Discuss the situation with the patient and help differentiate between real and imagined threats to well-being.

Nursing Diagnosis: RISK FOR DEFICIENT FLUID VOLUME related to vomiting.

Goal #1: Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, absence of vomiting.

Nursing Interventions (one must be education intervention):

1. Keep patient NPO as necessary

2. Maintain accurate record of intake and output. Assess skin and mucous membranes, peripheral pulses, and capillary refill.

3. Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.

4. Eliminate noxious sights or smells from environment.

Goal #2:

Nursing Interventions (one must be education intervention):

1.Administer antiemetics as appropriate

2.Maintain patent IV access, Set appropriate IV infusion rate and administer at a constant flow rate as ordered

3. Monitor serum and urine osmolality, serum sodium,BUN and hematocrit for elevations.

4. Position patient flat with legs elevated if hypotensive if not contraindicated.

Answer 1

Cholecystitis is a condition where there is a inflammation of the gall bladder.The main reason for the cholecystitis is the gall stones that leads to the irritation and later results in the inflammation of the gall bladder.Cholecystitis may sometimes results from blockage of the gall bladder resuting from a tumor and excessive alcohol use.But the main reason behind the cholecystitis is gall stones

Nursing diagnosis:

1.Risk for deficient fluid volume related to vomitting

2.Impaired verbal communication related to language barrier

3.Fear related lack of knowledge regarding the disease and its treatment plan

4.Low self esteem related to self criticism regarding her present condition.

Nursing diagnosis and intervention:

1.Risk for deficient fluid volume related to vomitting

Goal 1:Demonstrate adequate fluid volume balance evidenced by stablevital signs,moist mucous membranes,good skin turgor,capillary refill,individually appropriate urinary out put,absence of vomitting.

The education intervention to acheive the goal is to educate the patient regarding the importance of performing oral hygeine with a alcohol free mouth wash and apply lubricants to prevent the mucous membrane from drying and oral hygeine and brushing improving the circulation near to the mouth

Goal 2:Patient will have equal intake and out put with in 24 hours

The education intervention to acheive the goal is to educate the patient regarding the reasons behind the vomitting any way the patient is on NPO status.LR @ 125ml/hr is going on.Educate the patient regarding the importance of continuing the IV fluids to prevent dehydration

2.Impaired verbal communication related to language barrier

Goal 1:Patient uses form of communication to get needs met and to relate effectively with people and her environment

The education intervention to acheive this goal is educate the patient regarding the importance of verbal communication to understand regarding her condition and gain co-opration.Educate regarding the importance of the treatment of disease to her son he will educate the mother by their own language.

Goal 2:Patient communicates in a manner that can be understood by others with the help of medication and attentive listening by the time of discharge

The education intervention to acheive this goal is to communicate the patient through her son or through a nonverbal communication such as bodily action and gestures.Through this way educate the patient regarding the importance of nonverbal communication to open the psychological disturbances suffering by her and educate regarding different relaxation techniques to improve the strength of the mind.

3.Fear related to lack of knowledge regarding the disease and the treatment plan

Goal1:Patient identifies,vebalizes and demonstrate coping behaviours that reduce own fear

The education intervention to acheive this goal is educate the patient regarding the importance of relaxation techniques and doing meditation that improves the psychological strength and promotes a stress free mind.after coping with the present condition instruct them regarding the importance of following the treatment related to the condition and its benefits.

Goal 2:Patient verbalizes known fear

The education intervention to acheive the goal is to educate the patient regarding importance of diversional activities that relax the mind and thus patient verbalizes regarding the reason behind the fear

4.Low self esteem related to self criticism regarding her present condition

Goal 1:client can build a trusting relation with nurses

Nursing Interventions:

*Maintain a therapeutic self introduction with the patient

*Take time to listen to the client

*clarify the clients doubts by giving proper clarification

*Discuss the clients capabilities and skills owned by self

*Educate her regarding the self defence mechanism to improve the skills and psychological status

Goal 2:client can cope up with her present condition or acceptance of disease

*Plan the client activities done every day according to the ability

*Give a chance to try activities that have been planned

*Give praise for success

*Help prepare the family environment at home

*Give positive reinforcement for family involvement

*Give education regarding the care at home