Z`Ackley: Nursing Diagnosis Handbook, 12th Edition   Lecture Notes...

Z`Ackley: Nursing Diagnosis Handbook, 12th Edition

Lecture Notes

Problem-Based Learning/Critical Thinking

Case Study—Gloria McInerney Underweight & In Surgery

Case Scenario

Gloria McInerney is a 32-year-old divorced mother of two who presents to the emergency department (ED) at 9 AM with acute abdominal pain, nausea, vomiting, starting at 1 AM last night. Ms. McInerney is 64" tall and 100 pounds (BMI = 17.2). Her abdominal pain is located on the right side with rebound tenderness to the left. Her last meal was 5 PM the evening before when she ate two rice cakes for supper. Examination shows a ruptured appendix that calls for emergency surgery to prevent peritonitis complications.

Nursing Assessment

Ms. McInerney is a very thin Caucasian woman who has been divorced for 4 years and has shared custody of two school-age children. Ms. McInerney is a dance studio owner and instructor and works full time. She has no known allergies and her vital signs are blood pressure 96/60; temperature 101.8°F.; heart rate—110 beats per minute; respiratory rate—22 breaths per minute. She is reporting right sided abdominal pain at a 9 on a scale of 1 to 10. She is complaining of shivering and she is pale. Ms. McInerney has not eaten or drank in 36 hours. Preoperative consents are signed, and she is transported to the operating room (OR) for an immediate appendectomy.

A.   ASSESS

1.     Identify significant symptoms by underlining them in the assessment.

2.     List those symptoms that indicate the client has a health problem (those you have underlined).

3.     Group the symptoms that are similar.

B.    DIAGNOSE

1.     Select possible nursing diagnoses for this client.

LOOk into this By looking at the list of nursing diagnoses in, the book, Ackley/Ladwig Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care or by accessing the care plan constructor at the EVOLVE SITE and viewing nursing diagnoses listed there.

(You can copy and paste the information from the EVOLVE SITE in the areas below.)

Possible nursing diagnoses:

2.     Validate the possible nursing diagnoses.

Compare the signs and symptoms (defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. Also read the definition and determine if this diagnosis fits this client.

Validated nursing diagnoses include:

3.     Write/select a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the related to (r/t) factors.

a.      The label is the title of the nursing diagnosis as defined by NANDA-I.

b.     A related to (r/t) statement describes factors that may be contributing to or causing the problem that resulted in the nursing diagnosis.

(You can copy and paste the information from the EVOLVE SITE in the areas below.)

NANDA-I label:

Definition:

Risk factors:

The complete nursing diagnostic statement is:

C.   PLAN

1.     Select appropriate NOC outcome from Ackley/Ladwig text or from the EVOLVE Care Plan constructor.

(You can copy and paste the information from the EVOLVE SITE in the areas below.)

NOC outcome:

2.     Fill out the grid with NOC indicators and the appropriate Likert scale.

Select the appropriate point on the Likert scale to measure the client's current status.

INDICATOR

1 = Severe

2 = Substantial

3 = Moderate

4 = Mild

5 = None

Increased skin temperature

Decreased skin temperature

Skin color changes

Dehydration

Hypothermia

3.      Write outcomes to help resolve the symptoms (defining characteristics). Refer to Section III of the Ackley/Ladwig text for the nursing diagnosis care plan or the EVOLVE Care Plan constructor.

Outcomes:

Select appropriate NIC interventions from Ackley/Ladwig text or care plan constructor.

NIC intervention:

4.     Select appropriate NIC activities.

Note: The Ackley/Ladwig text and the care plan constructor gives sample NIC activities.

5.     Select interventions from the Section III care plan or the care plan constructor that will enable the client to attain acceptable outcomes.

Nursing Interventions and Rationales

D.   IMPLEMENT

The next step in the nursing process is to give the nursing care utilizing the nursing interventions.

E.    EVALUATE

After putting into effect, the nursing interventions, the results of the care should be evaluated by determining if the outcomes were met. If the outcomes are acceptable, the care plan is resolved. If the outcomes are not acceptable, further assessment should be done to answer the following questions:

NOC indicator

Rating at admission

Rating 30 minutes later (postoperative)

Rating 1 hour later (postoperative)

Increased skin temperature

Decreased skin temperature

Skin color changes

Dehydration

Hypothermia

·        Was the correct nursing diagnosis chosen?

·        Was the outcome appropriate?

·        Were the interventions appropriate in this situation?

·        What other interventions might have been helpful?

Changes in the nursing diagnosis, outcomes, and interventions should be made as needed. This is continued use of critical thinking to ensure appropriate nursing care.

Click here to access the Ackley, Ladwig Care Plan Constructor to assist you in formulating your care plan. EVOLVE

 

Answer:

A.   ASSESS

1.     Identify significant symptoms by underlining them in the assessment.

Gloria McInerney is a 32-year-old divorced mother of two who presents to the emergency department (ED) at 9 AM with acute abdominal pain, nausea, vomiting, starting at 1 AM last night. Ms. McInerney is 64" tall and 100 pounds (BMI = 17.2). Her abdominal pain is located on the right side with rebound tenderness to the left. Her last meal was 5 PM the evening before when she ate two rice cakes for supper. Examination shows a ruptured appendix that calls for emergency surgery to prevent peritonitis complications.

Ms. McInerney is a very thin Caucasian woman who has been divorced for 4 years and has shared custody of two school-age children. Ms. McInerney is a dance studio owner and instructor and works full time. She has no known allergies and her vital signs are blood pressure 96/60; temperature 101.8°F.; heart rate—110 beats per minute; respiratory rate—22 breaths per minute. She is reporting right sided abdominal pain at a 9 on a scale of 1 to 10. She is complaining of shivering and she is pale. Ms. McInerney has not eaten or drank in 36 hours. Preoperative consents are signed, and she is transported to the operating room (OR) for an immediate appendectomy.

2.     List those symptoms that indicate the client has a health problem (those you have underlined).

• Nausea
• Vomiting
• Decreased blood pressure (96/60 mmHg)
• Fever/Pyrexia (101.8°F)
• Tachycardia (110 beats per minute)
• Tachypnea (22 breaths per minute)
• Abdominal pain (right side, rebound tenderness to the left; 9/10)
• Shivering
• Pale skin

3.     Group the symptoms that are similar.

General:

• Shivering
• Abdominal pain (right side, rebound tenderness to the left; 9/10)
• Fever/Pyrexia

Cardiopulmonary:

• Tachycardia (110 beats per minute)
• Tachypnea (22 breaths per minute)
• Decreased blood pressure (96/60 mmHg)

Integumentary:

• Pale Skin

Gastrointestinal:

• Nausea
• Vomiting

B.    DIAGNOSE

1.     Select possible nursing diagnoses for this client.

Possible nursing diagnoses:

• Deficient Fluid volume r/t anorexia, nausea, vomiting
• Acute Pain r/t inflammation
• Risk for Infection: Risk factor: possible perforation of appendix
• Readiness for enhanced Knowledge: expresses an interest in learning

2.     Validate the possible nursing diagnoses.

Validated nursing diagnoses include:

• Deficient Fluid volume r/t nausea, vomiting
• Risk for Infection: Risk factor: possible perforation of appendix
• Acute Pain r/t inflammation

 

3.     Write/select a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the related to (r/t) factors.

 

NANDA-I label: Risk for Deficient Fluid Volume

Definition:Vulnerable to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which

may compromise health

Risk factors: Nausea, vomiting

The complete nursing diagnostic statement is: Risk for Deficient Fluid Volume r/t nausea, vomiting

C.   PLAN

1.     Select appropriate NOC outcome from Ackley/Ladwig text or from the EVOLVE Care Plan constructor.

NOC outcome: Hydration

2.     Fill out the grid with NOC indicators and the appropriate Likert scale.

Select the appropriate point on the Likert scale to measure the client's current status.

INDICATOR

1 = Severe

2 = Substantial

3 = Moderate

4 = Mild

5 = None

Increased skin temperature - 2

Decreased skin temperature - 5

Skin color changes - 2

Dehydration- 2

Hypothermia- -5

3.      Write outcomes to help resolve the symptoms (defining characteristics). Refer to Section III of the Ackley/Ladwig text for the nursing diagnosis care plan or the EVOLVE Care Plan constructor.

Outcomes:

• Maintain urine output of 0.5 mL/kg/hour or at least more than 1300 mL/day
• Maintain normal blood pressure, heart rate, and body temperature
• Maintain elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, and time
• Explain measures that can be taken to treat or prevent fluid volume loss
• Describe symptoms that indicate the need to consult with health care provider

Select appropriate NIC interventions from Ackley/Ladwig text or care plan constructor.

NIC intervention:

4.     Select appropriate NIC activities.

• Monitor hydration status (e.g., moist mucous membranes, adequacy of pulses, and orthostatic blood pressure) as appropriate;
• Administer intravenous (IV) therapy, as prescribed

5.     Select interventions from the Section III care plan or the care plan constructor that will enable the client to attain acceptable outcomes.

Nursing Interventions and Rationales

• Watch for early signs of hypovolemia, including thirst, restlessness, headaches, and inability to concentrate. Thirst is often the first sign of dehydration (Wagner & Hardin-Pierce, 2014). CEB: A study of healthy women showed heart rate was increased by fluid restriction along with increased urine specific gravity, darker urine color, and increased thirst. They also experienced decreased alertness and increased sleepiness, fatigue, and confusion (Pross et al, 2013).
• Monitor pulse, respiration, and blood pressure of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client and every 4 hours for the stable client. Vital sign changes seen with fluid volume deficit include tachycardia, tachypnea, decreased pulse pressure first, then hypotension, decreased pulse volume, and increased or decreased body temperature (Wagner & Hardin-Pierce, 2014).
• Provide clear liquids in small amounts when oral intake is resumed, and progress diet as tolerated. Maintenance of oral intake stabilizes the ability of the intestines to absorb nutrients and promote gastric emptying (Popkin et al, 2010)
• Hydrate the client with ordered isotonic IV solutions if prescribed. For clients with mild to moderate fluid deficit, crystalloids such as 0.9 saline or lactated Ringer's should be used for fluid volume replacement (Peng & Kellum, 2013)

D.   IMPLEMENT

The next step in the nursing process is to give the nursing care utilizing the nursing interventions.

E.    EVALUATE

After putting into effect, the nursing interventions, the results of the care should be evaluated by determining if the outcomes were met. If the outcomes are acceptable, the care plan is resolved. If the outcomes are not acceptable, further assessment should be done to answer the following questions:

NOC indicator

Rating at admission

Rating 30 minutes later (postoperative)

Rating 1 hour later (postoperative)

Increased skin temperature

Decreased skin temperature

Skin color changes

Dehydration

Hypothermia

·        Was the correct nursing diagnosis chosen?

·        Was the outcome appropriate?

·        Were the interventions appropriate in this situation?

·        What other interventions might have been helpful?

Changes in the nursing diagnosis, outcomes, and interventions should be made as needed. This is continued use of critical thinking to ensure appropriate nursing care.

Source:

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.