Case Study Grid

Topics: Nursing care plan, Nursing diagnosis, Obesity Pages: 3 (581 words) Published: April 3, 2015
University of Phoenix Material

Case Study Grid

List five factors of the patient’s history that demonstrates nursing needs. 1. Limited social support in and out of the hospital
2. Weight loss
3. Lack of knowledge about the importance of self-breast examination 4. Smokes approximately two packs of cigarettes a day.
5. No emotional support from her spouse, and abusive spouse

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 radical hysterectomy as evidenced by report of 8/10 pain and grimacing

Desired Outcome 1
Patient will report minimal pain with minimal interference of ADLs by hospital day 2 Desired Outcome 2
Patient will demonstrate use of relaxation skills and diversional activities by the end of hospital day 3 Nursing Intervention 1

Determine the location, frequency and duration of pain in a scale of 0-10 Provide non pharmacological activity measures like repositioning and offering comfort measures Nursing Intervention 2

Administer analgesics as indicated and also Inform patient of the expected therapeutic effects and discuss management of side effects Encourage use of stress management...
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