Nursing 403 Debbie Case Study

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Case Study Grid

List five factors of the patient’s history that demonstrates nursing needs:

1. Does not perform self breast exams. 2. Smoking 2 packs per day for 16 years 3. Weight loss 4. Oral contraceptives and smoking increase blood clot risk 5. Infrequent medical care

Complete the table below with the following information:

• Formulate three nursing diagnoses using the Problem, Etiology, and Signs and Symptoms (PES) format and the taxonomy of NANDA. The diagnoses must be based on the case study, be appropriate, be prioritized, and be formatted correctly.

• For each nursing diagnosis, state two desired outcomes using NOC criteria. Desired outcomes must be patient-centered and measurable within an identified timeframe.

• For each outcome, state two nursing interventions using NIC criteria as well as one evaluation method. Interventions and the evaluation method must be appropriate to the desired outcomes.

• Provide rationale for each nursing diagnosis, and explain how PES, NANDA, NOC, and NIC apply to each diagnosis.

Use a minimum of three peer-reviewed resources, and create an APA formatted reference page.

Nursing Diagnosis 1: Acute pain related to post-operative surgery as evidenced by patient self-report of pain.

| |Desired Outcome 1 |Desired Outcome 2 |
|Nursing Intervention 1: Monitor |Patient self-report satisfactory pain control from 3-4 on scale of 0-10 pain |Patient will use pharmacological and non-pharmacological pain relief as needed |
|pain on scale of 0-10 every shift.|scale. |by the time hospital discharge.

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